YALE UNIVERSITY

LIBRARY

From the Medical Library of

DR. ALEXANDER LAMBERT, B.A. 1884

the gift of

DR. ADRIAN LAMBERT, B.A. 193°

DR. JOHN T. LAMBERT, B.A, 1935

DR. SAMUEL W. LAMBERT, JR., B.A. 1919

DR. DICKINSON W. RICHARDS, JR., B.A. 1917

TRANSFERRED TOYALE MEDICAL LIBRARY

ON ALCOHOLISM

ON

ALCOHOLISMITS CLINICAL ASPECTS

AND TREATMENT

FRANCIS HARE, M.D.

MEDICAL SUPERINTENDENT OF THE NORWOOD SANATORIUM,

BECKENHAM

LONDON

J. & A. CHURCHILL7, GREAT MARLBOROUGH STREET

1912

PRINTED BY ADLARD AND SON,

LONDON AND DORKING.

811. VA

PREFACE

In the middle of 1905, the medical side of the

Norwood Sanatorium was taken over by a committee

of well-known medical men whose number has since

been slightly increased. Since the end of that year

the experience gained in the institution has been

embodied in quarterly reports, addressed to, and

passed by, the Committee at their quarterly meetings.

At the end of each year the substance of the quarterly

reports has been re-embodied in an annual report,

which, after acceptance by the Committee at their

annual meeting, has been printed and circulated

amongst members of the medical profession. Five

such annual reports have now been issued, and,

judging by the number applied for and the tone of

the acknowledgments received, have met with a

measure of appreciation : this applies more especially

to the third, fourth and fifth annual reports, which

have naturally been longer and more exhaustive than

the first and second. Accordingly it has been sug-

gested that the time has arrived to collocate and re-

arrange the material contained in these annual

reports in a form more convenient for reference, and

the present volume is the outcome of that sugges-

tion.

VI PREFACE

For the most part alcoholism has been studied

clinically under three conditions: (i) In general

practice : (2) in general hospitals ; and (3) in licensed

retreats. Each of these fields of study provides a

somewhat different point of view. The physician in

general practice obtains his cases in a comparatively

early stage. This is considerably in his favour. On

the other hand, he is obliged in most instances

to treat his patients in their own homes amongst their

accustomed surroundings—surroundings in which

the habit has developed. This is not in the physi-

cian's favour ; for it is always difficult for him to feel

assured that his prescribed treatment is being strictly

carried out. The hospital physician sees mainly the

advanced cases of alcoholism—cases in which the

severity of the ultimate degenerations and physical

complications overshadow the earlier and more

remediable stages of the affection ; while the physi-

cian in charge of a retreat licensed under the Ine-

briates Act, armed as he is with no small amount of

legal authority, sees his patients in circumstances

which are certainly exceptional, if not quite abnormal.

Moreover, owing to the natural aversion of patients

from signing away their individual freedom even for a

time, he can hardly expect to obtain his cases in

other than the later stages of alcoholism.

All such considerations encourage the hope that

the clinical study of alcoholism in a free sanatorium

will provide one or two new points of view, and so

lead to, if it does not directly promote, an increase

in the definite knowledge we now possess of this

ubiquitous habit or disease.

In works on alcoholism and its treatment it is

PREFACE Vll

usual to refer also to the management of other drug

habits. That course has not here been followed.

The subject of morphinism, the only other drug

habit at all common in this country, has been

thought worthy of a volume to itself, and conse-

quently deferred.

The first or introductory chapter stands somewhatapart from those which follow. It is theoretical and

deductive, and was inspired mainly by the views put

forward in the recent report of the Departmental

Committee on the law relating to inebriates and

their detention. To my mind these views are of

extreme interest and even of great practical import-

ance. But the chapter is not clinical in its origin,

and unlike the remaining eight chapters, does not

depend upon the work done at the Norwood Sana-

torium. The busy practitioner, therefore, mayperhaps elect to omit its perusal.

Beckenham,

August, 1912.

CONTENTSCHAPTER I

IntroductoryPAGB

Nature of inebriety—Motives for drinking—Generallyaccepted propositions concerning alcohol—Classifica-

tion of population from an alcoholic standpoint

—

Classification of inebriates from a psychological

standpoint—Inexpediency of regarding inebriety as

a disease i

CHAPTER II

Exciting, determining, or accentuating factors of alcoho-

lism—Extrinsic : grief, worry, boredom, and variations

in responsibility ; special occupations ; example, goodand bad—Intrinsic, mostly pathological : pyrexial

conditions and convalescence therefrom ; insanity;

abnormal mental conditions not amounting to insanity

;

mental depression ; insomnia ; debilitating condi-

tions ; dysmenorrhcea ; asthma ; recurrent neuralgic

and allied painful conditions;

paroxysmal tachy-

cardia ; eye-strain ; morphinism; gout ... 14

CHAPTER III

Clinical classification of alcoholism : recurrent, or inter-

mittent ; chronic, or continuous — Dipsomania —Pseudo-dipsomania—Chronic or continuous alcoho-

lism, inebriate and sober— Intermediate cases;

absence of sharp lines of demarcation between the

four varieties of alcoholism ; consequent difficulty of

classification— Dipsomaniac craving and alcoholic

craving • • • 59

CONTENTS

CHAPTER IV

Symptoms and complications — Acute complications,

mental and other—Chronic mental complications-

Alcoholic peripheral neuritis—Alcoholic albuminuria

—Hepatic complications—Gastric catarrh and vomit-

ing 92

CHAPTER V

Abstinence phenomena of alcoholism—Natural tolerance

—Acquired tolerance : alcoholic insomnia ; tolerance

of morphine ; tolerance of chloral ; tolerance of

veronal ; tolerance of cocaine—Loss of acquired tole-

rance—Intolerance : pathological drunkenness ; mania

a potu—Affections arising during and after convales-

cence from alcoholism : recurrent or periodic ano-

rexia ; recurrent or periodic "bilious" attacks; re-

current sick headache ; recurrent or periodic diarrhcea

;

recurrent or periodic migraine ; morning headaches ;

persistent high blood-pressure; acute articular gout 113

CHAPTER VI

Alcoholic epilepsy and delirium tremens—Alcoholic epi-

lepsy : cases occurring in sanatorium ; cases which

occurred before admission ; conclusions—Delirium

tremens : cases occurring in sanatorium ; cases which

occurred before admission ; conclusions, special andgeneral ; differences in incidence between alcoholic

epilepsy and delirium tremens—Alcoholic epilepsy

and delirium tremens combined—Abortive treat-

mentof delirium tremens—Somefallacies regardingthe

pathology of delirium tremens—Theories of delirium

tremens—Prognosis of delirium tremens and alcoholic

epilepsy—Treatment of delirium tremens and alco-

holic epilepsy 140

CHAPTER VII

Treatment—Compulsion and moral tone—Voluntary re-

strictions—Policy in free sanatorium—Diet—Tobacco 178

CONTENTS XI

CHAPTER VIIIPAOR

Treatment (continued)—The withdrawal of alcohol : cases

suited for sudden withdrawal ; cases suited for taper-

ing ;principles of successful tapering—Special drugs

used : apomorphine hydrochloride ; sodium bromide;

special hypnotics ; strychnine, atropine, cinchona

rubra, and gentian ; morphine tartrate ; rationale of

action of drugs used in alcoholism—Duration of treat-

ment ; after-treatment ;parting advice . . 208

CHAPTER IX

General results—Fallacies : incomparability of results;

incomparability of data—Statistics : percentage of

relapses, of cases stated to be improved, and of

abstainers ; known duration of abstinence following

treatment ; results in individual patients — Somefactors bearing on prognosis : heredity ; sex ; age

;

form of alcoholism 244

INDEX . . . .263

ON ALCOHOLISM

CHAPTER I

INTRODUCTORY

Nature of inebriety—Motives for drinking— Generally acceptedpropositions concerning alcohol—Classification of populationfrom an alcoholic standpoint—Classification of inebriates froma psychological standpoint— Inexpediency of regarding in-

ebriety as a disease.

Is inebriety a disease? This is one of the com-monest questions put to the physician who devotes

his attention mainly to alcoholism. Unfortunately

no straightforward answer can be made. In the

first place the term " disease " has never been clearly

and comprehensively defined. We might, of course,

beg the latter question to some extent and define

disease as unphysiological action. Then, however,

we should have to admit that there is no clear line

of demarcation between physiological and unphysio-

logical, or pathological, action. And it is equally

certain that there is no clear line of demarcation

between strictly moderate drinking and drinking to

excess. There are, it is true, some who regard all

consumption of alcohol, in whatever form, as patho-

logical, and these certainly gain the advantage of

evading a difficulty. But in the present state of

public opinion, the advancement of such a view

—

2 ON ALCOHOLISM

whether it prove eventually right or wrong—is, for

the practical physician, at any rate, to be avoided.

It is for him a heavy handicap in seeking to gain the

confidence of the ordinary alcoholic patient with

whom he has to deal. I do not deny that the con-

stant ventilation of views in advance of the average

opinion of the public may have been an efficient

agent in bringing about the present very general

reaction against the use and abuse of alcohol in

daily life. But I do maintain that for the physician

practising alcoholism, as distinguished from the

propagandist, it is impolitic to incur the suspicion

of being an extremist : the extremist will inevitably

find that all his arguments are discounted.

It is safe to say that alcoholism in many cases

amounts to a disease ; but it is impossible to deny

that very often the habit is more properly regarded

as in the main an exaggeration of ordinary self-

indulgent drunkenness ; while between these twoextremes lies an extended series of intermediate

cases—cases in which morbidity and viciousness

enter in all proportions into the causation.

It is impossible, therefore, to refer inebriety finally

either to the domain of disease or of vice. But wecan seek to disentangle the fundamental factors of

inebriety, and so form an approximate estimate in

individual cases of the amount of responsibility

—

past and present—to be attributed to the patient.

In the first place, it is necessary to clear theground by referring to the motives which lead mento drink. These are well put by Archdall Reid.*They are essentially threefold. Men drink (i) to

* ' Principles of Heredity,' 1905, p. 190.

MOTIVES FOR DRINKING 3

satisfy thirst : (2) to gratify taste : and (3) to induce

those peculiar feelings or frames of mind which arise

when alcohol circulating in the blood acts directly

on the brain—technically, alcoholic euphoria.

The three motives are essentially different,

although it is certain that the majority of those

who are incidentally, or even personally, interested

in the drink question, entirely fail to differentiate

between them. For example, I am frequently

asked, " How can you expect atropine to assist in

keeping a patient abstemious when one admitted

action of the drug is to cause dryness of the mouth

and throat, and consequent thirst ? " The answer

is, of course, that thirst never impels the sufferer to

take alcohol : for the thirsty man, water is the main,

if not the sole, consideration, even although he mayadd some alcoholic fluid to improve the flavour of

the drink ; when really thirsty, he would far prefer

the water without the alcoholic addition to alcohol

without the water. Any antagonism which exists

between atropine and alcohol concerns only the

third motive for drinking : thirst and craving for

alcohol are no more allied than thirst and craving

for morphine.

Again, patients frequently say :" I don't drink

whisky (or other spirit as the case may be) because

I like it. As a matter of fact, I don't like it. I

drink because I have to." Disentangled from

verbal fallacies, this statement means that whisky

and its like fail to gratify their palate, but satisfy,

more or less completely, their craving for alcoholic

euphoria.

For the connoisseur who drinks to gratify taste,

4 ON ALCOHOLISM

the flavour is the main consideration : the water and

alcohol are used merely to bring out, or modify, the

flavour. His motive is identical with that of a child

eating toffee.

For the alcoholist the brain effect—the euphoria

—

is the sole object : so long as his beverage contains

alcohol he will drink to satiety, even in the absence

of any thirst, and even when his liquor is actually

disagreeable. Eau-de-Cologne, rectified, or even

methylated spirit, may be eagerly consumed in the

absence of more palatable fluids.

The toper is quite impossible as a critical taster of

ales, wines, or spirits, and that for two reasons : the

natural delicacy of his palate is usually destroyed

through constant stimulation by the more ardent

alcoholic fluids ; and his craving for the cerebral

effects of alcohol blurs his capacity for estimating

sensations which are for him entirely subordinate.

As the old toper is reported to have remarked, " Thereis no such thing as bad whisky."

Both the above results of chronic alcoholism are

illustrated, if not fully explained, by observations of

various kinds in the sanatorium. The loss of taste,

and its limited but rapid recovery, are seen in patients

for whom mixtures containing drugs like capsicumand ginger are prescribed as substitutes for alcoholduring the early days after admission. Usually,within a week, the patient will complain that thestrength of his medicine has been greatly increased

;

and so assured will he be that this is true, that quiteoften he will be clearly dissatisfied when matters areexplained to him. The complete loss of perceptivityof the more delicate flavours of matured spirits, etc.,

MOTIVES FOR DRINKING 5

is also obvious. A certain percentage of patients

require, and are given, alcohol (whisky, brandy, etc.)

in decreasing doses during the early days after

admission into the sanatorium. And it is significant

that in the last few years criticism of the liquor

supplied has been unknown : in the patient's eyes it

has been all good, though occasionally in reality ot

quite indifferent quality. There are many types of

drinking to be observed. But the drinker whohabitually sips his liquor, and ceases from con-

versation while he thoughtfully and critically rolls

it round his mouth, may assuredly (unless he be

acting) be excluded from the category of alcoholists,

at the time the observation is made.

Though entirely distinct, the three motives mayof course co-exist in the one individual ; or, as is

common, they may succeed each other. In this

case, the last motive, the desire for alcoholic

euphoria, eventually over-rides and displaces the

former two, which thenceforward cease to have any

material bearing on the case.

The former two of the motives for drinking, the

relief of thirst and the gratification of taste, can

never lead to excess for the reason that both rapidly

disappear through the early advent of satiety : thirst

ceases when the deficiency of water in the system is

made good, and the palate becomes quickly cloyed.

The third motive is not of necessity so safeguarded.

Therefore it is with this motive only that we are

henceforward concerned.

The problem of the nature of inebriety, as pointed

out in the recent report of the Departmental Com-mittee on the law relating to inebriates and their

6 ON ALCOHOLISM

detention*—a report of which I am making the

freest possible use throughout the remainder of this

chapter—is best approached deductively, that is

through the avenue of propositions that are

generally accepted. Amongst these propositions

are the following

:

(i) No desire for the consumption of intoxicants

—

alcohol, opium, betel, kava, coca, kola, haschisch, etc.

—exists antecedent to their use. Savage races and

civilised persons who have never taken alcohol, etc.,

have no desire for them whatever, however insensate

their craving may become when once they have

indulged.

(2) The capacity for being pleasurably affected by

alcohol or other intoxicant is a fundamental fact in

human nature : this capacity exists also in some of

the lower animals.

(3) The enjoyment derived, though practically

universal, is experienced by different individuals in

very different degrees.

(4) In all, a certain quantity of alcohol producesthe familiar symptoms of intoxication. The quantity

required, however, varies (a) with the individual:

(b) with the rapidity with which the alcohol is

taken ; and above all (c) with the degree of toleranceof alcohol which has been established by previousprolonged consumption of alcohol. The symptomsalso vary with the individual, with the amount, andwithin certain limits, with the kind, of liquor taken.

(5) In the great majority, the use of alcohol(and of other intoxicants) gives rise at length to

* London : Wyman & Sons;also ' Brit. Med. Journ. Supplement '

January 16th, 1909, p. 25.

GENERAL PROPOSITIONS 7

satiety, that is, to temporary distaste for further

consumption.

(6) The quantity needed to produce satiety varies

greatly in different individuals, and in the sameindividual in different circumstances.

(7) In some, satiety is produced before intoxication

occurs : in others, intoxication occurs before satiety

is produced.

From these propositions, which are hardly open to

question, it may be concluded that when satiety

precedes intoxication, the person affected is in nodanger of becoming intoxicated—temptation is

absent ; and that when intoxication precedes

satiety, the person affected will go on drinking

until he becomes intoxicated, unless other influences

intervene.

By means of this general conclusion, we maydivide all that part of the population who have ever

at any time had experience of alcoholic euphoria

into the following four classes :

(1) Those who habitually remain sober through absence

of intrinsic temptation. In such satiety is produced

before—often long before—intoxication could occur

:

there is no danger of excess. It is illogical to assume

that inebriates and the sober differ mainly as regards

their powers of self-control—that the habitually tem-

perate are of necessity endowed with greater will-

power than those who succumb from time to time

to alcoholic excess. Yet almost without exception,

the relatives and friends of patients brought to the

sanatorium speak always of absence of will-power,

completely ignoring the existence of variations in

the strength of temptation.

8 ON ALCOHOLISM

The fact is that many habitually abstemious

people are obviously of feeble will-power in all the

relations of every-day life : they may appear to be

strong in resisting the temptation to alcoholic excess,

but the truth is that, for them, alcoholic excess has

no temptation—at any rate, no adequate temptation.

Probably, and fortunately, the great mass of the

habitually temperate may be ranged under this

head. Such are fond of proclaiming their complete

inability to understand why anyone should ever

drink too much—an inability which, from their

point of view, is easily realised.

(2) Those who remain habitually sober through exertion

of will-power. Such would attain to the stage of

intoxication before that of satiety, yet habitually fall

short of either stage through the intervention of

influences hostile to intoxication. In other words,they are not actuated solely by self-indulgent

motives. They foresee the danger of becomingintoxicated; and under the influence of a numberof desires conflicting with the still unquencheddesire for drink—for example, self-respect, the wishto retain the respect of others, the fear of financial

loss, even the mere anticipation of the mental andphysical punishment which invariably follows adebauch—exercise their volition and cease fromdrinking. In this class the power of self-control

is stronger than the desire for intoxication. Theclass is no doubt considerable, but is certainly muchsmaller than Class 1.

(3) Those who deliberately become intoxicated at times.

In such also intoxication precedes satiety, or doesso at the crucial times. Persons under this head

INDELIBERATE DRUNKARDS : INEBRIATES 0,

possess sufficient will-power to cease drinking before

the stage of intoxication is reached, but they do not

always exert their volition in this respect. Either

they are insufficiently alive to the disadvantages of

intoxication ; or realising them, deliberately decide

that such disadvantages are more than counter-

balanced by the enjoyment of intoxication. Of such

kind are the class of week-end and bank-holiday

drunkards, etc.

(4) Those who become intermittently, periodically, or

constantly intoxicated, but whose action in this respect is

for the most part, if not always, indeliberate. Such,

and such only, constitute the class of inebriates.

Here, as in classes 2 and 3, intoxication necessarily

precedes satiety. But the saving influence of will-

power is lacking—it is at any rate inadequate, or

inadequate at times. There is an alteration in the

ratio between self-control and the desire for drink. It

may be that the chief fault is an exaggerated appre-

ciation of alcoholic euphoria, self-control remaining

normal or approximately so ; or the chief fault maybe a deficiency of self-control, the appreciation of

alcoholic euphoria remaining normal or approxi-

mately so. Finally, it would appear that both the

exaggerated appreciation of alcoholic euphoria, and

the deficiency of self-control, may be either more or

less inherent or very largely acquired.

Classification of Inebriates in accordance with

the Psychological Factors of Inebriety.

The comprehensive definition of inebriety in-

volved in the last (fourth) paragraph leads to the

10 ON ALCOHOLISM

formulation of an imperfect, but more or less natural,

classification of inebriates—a classification, that is

to say, dependent on psychological causation. This

is threefold

:

(i) Those who are endowed with an exaggerated

appreciation of alcoholic euphoria, but whose power

of self-control is not commensurately increased.

" Deriving more pleasure than others from the use

of alcohol, they desire it more strongly. Desiring it

more strongly, they need a corresponding increase

of self-control to enable them to abstain from its

excessive use. Such persons are not necessarily

deficient in intelligence, strength of will, or desire to

keep sober. They may be superior to tlie average in

some or all of these qualities {italics mine) ; but desire

for drink is in them so greatly intensified, that a

capacity for self-control, even if beyond the average,

is insufficient to keep them from excess. Suchpersons are often of great capability and intelligence,

and frequently are members of families in whichother examples of this form of inebriety occur. Thedesire for drink, which may be very great, is often

intermittent or paroxysmal in occurrence, and the

amount of alcohol taken is often enormous." Thebest examples of inebriates coming under this headare the true dipsomaniacs (see p. 60).

(2) Those who, with or without an exaggeratedappreciation of alcoholic euphoria, are deficient in

self-control. Such "lack either the intelligence to

appreciate the ill-effects of drunkenness or the force

of character and strength of will necessary to with-stand the appeal of a desire for immediate indulgenceat whatever cost of future detriment. The lack of

PSYCHOLOGICAL CLASSIFICATION II

self-control shows itself not only in inability to with-

stand the allurements of alcohol "—were this the

only evidence, nothing, of course, would be proved

—

" but also in outbreaks of temper, of violence, of

restlessness, or of destructiveness upon slight provo-

cation." Short of all this, there is evidence of lack

of self-restraint in many directions ; such patients,

for example, when they have recovered their appetite

and digestive power, often eat far too much, and at

all times they are apt to smoke too much. They are

frequently, too, deficient in intelligence, and maycome of families in which there are other instances

of mental disorder. In them quite a small amountof alcohol may be enough to cause intoxication

:

there may be a natural intolerance of alcohol (vide

p. 127) ; and amongst them are to be found most of

the examples of what has been termed " pathological

drunkenness." *

(3) The exaggerated appreciation of alcoholic

euphoria and the deficient self-control referred to in

classes 1 and 2 are for the most part congenital—at

any rate, inherent ; they are temperamental. But

both may be acquired. " By continued indulgence,

the desire for liquor is increased . . . whatever

the reason that led to the habit, it is found that the

longer the habit is continued, the greater becomes

the desire for the drug." And furthermore, " by

continual yielding to desire, and continued failure to

exert self-control . . . self-control is weakened

until it is reduced permanently below the point

necessary to overcome the desire, and thus inebriety

is established. Inebriates of this class are miscel-

* ' Brit. Med. Journ.,' 1910, p. 36.

12 ON ALCOHOLISM

laneous in character. Sometimes they approach to

class i and class 2 in family history and mental

qualities, but often have little apparent affinity to

either. They are inebriates by artificial culture

rather than by nature, and when they are defective

or disordered, the defect or disorder is often the

consequence rather than the cause of the drinking

habit."

That part of the report of the Departmental

Committee which deals with the nature of inebriety

concludes as follows :" This view of inebriety which

regards it as an alteration of the ratio of self-control

to desire for drink throws light upon the question

whether or not it should be regarded as a disease.

It is undoubtedly a constitutional peculiarity, and

depends in many cases upon qualities with which a

person is born, in many acquired by vicious indul-

gence. Whether the possession of such a constitu-

tional peculiarity when inborn should or should not

be considered, from the scientific point of view, a

disease, is perhaps a question of nomenclature. If

such native peculiarities as the possession of a sixth

finger and the absence of a taste for music are

rightly considered disease, then the native constitu-

tional peculiarity which underlies many cases of

inebriety may be so considered. But there are

cogent reasons why the term " disease " should not be

used to characterise the inebriate habit. By disease

is popularly understood a state of things for whichthe diseased person is not responsible, which he

cannot alter except by the use of remedies from

without, whose action is obscure, and cannot be

influenced by exertions of his own. But if, as is

HABIT OR DISEASE 13

unquestionably true, inebriety can be induced by

cultivation, if the desire for drink can be increased

by indulgence, and self-control diminished by lack

of exercise, it is manifest that the reverse effects

can be produced by voluntary effort, and that desire

for drink may be diminished by abstinence, and self-

control, like any other faculty, can be strengthened

by exercise. It is erroneous and disastrous to

inculcate the doctrine that inebriety, once established,

is to be accepted with fatalistic indulgence, and that

the inebriate is not to be encouraged to make any

effort to mend his ways. It is the more so since

inebriety is in many cases recovered from . . .

and since the cases which recover . . . are

those in which the inebriate himself desires and

strives for recovery."

There can be no doubt that this is wise counsel.

Physicians who have had a large experience of

inebriates must all recognise that there is a numerous

class of patients who are only too willing to escape

responsibility for their habit, and who eagerly

embrace any argument which seems likely to assist

them to attain that end.

CHAPTER II

Exciting, determining, or accentuating factors of alcoholism—Ex-

trinsic : Grief, worry, boredom, and variations in responsibility;

special occupations; example, good and bad—Intrinsic, mostly

pathological: pyrexial conditions and convalescence therefrom;

insanity; abnormal mental conditions not amounting to insanity;

mental depression; insomnia; debilitating conditions; dys-

menorrhcea, asthma, recurrent neuralgic and allied painful con-

ditions; paroxysmal tachycardia ;eye-strain ;

morphinism;gout.

The threefold natural classification outlined in

the last chapter involves—indeed, depends upon—the

fundamental psychological factors of inebriety. There

may be an exaggerated appreciation of alcoholic

euphoria, or a power of self-control below the average,

and both factors may be inborn or acquired. To-

gether it will be convenient to refer to these as the

predisposing factors. But in the clinical history of

an inebriate, there are nearly always other factors

bearing upon the habit—factors which may be termed

exciting, determining or accentuating. Such factors

may all occur in those who have no tendency to

alcoholism : they are then powerless to cause

inebriety : behind them must always stand the

predisposing factors, whether inborn or acquired.

Yet the exciting factors are often the starting-point

of the habit, and their continued existence mayprove the main obstacle to permanent convalescence.

EXTRINSIC EXCITING FACTORS 15

Fortunately, however, they are the most removable

of the factors : hence, on all grounds, the necessity

for their recognition and treatment.

To attempt an exhaustive enumeration of the ex-

citing factors of inebriety would be a hopeless, as

well as a needless, task. Such a list would cover

most of the field of medicine and surgery, and extend

thence into nearly all the circumstances of daily life.

Reference here will be made only to those factors

which have come frequently under notice at the

sanatorium, which are presumably the commonestand most important, and which have in these cases

undoubtedly contributed to the patient's condition.

These factors may be divided primarily into

extrinsic—factors circumstantial which are for the

most part, if not wholly, independent of the patient's

control, or even of his personality ; and intrinsic—factors which, whether inherent or acquired, are, or

have become, a part of the patient's personality, and

which may, or may not, be controllable by himself.

Extrinsic Factors.

Amongst extrinsic factors, the most frequently

recurring are grief, from the illness or death of near

relatives or intimate friends : sudden adversity from

financial loss : infidelity on the part of husbands or

wives : broken engagements of marriage ; and

numerous other misfortunes, business and domestic.

An even more efficient factor than grief is worry,

which also may be of a business or domestic nature.

Grief, though often determining inebriety in a hitherto

moderate drinker, not very rarely operates in the

l6 ON ALCOHOLISM

reverse direction, and checks the downward career

of the incipient inebriate. There is a certain finality

about grief—a cessation of responsibility for the

future—which would seem to be in some cases

beneficial. Worry, on the other hand, connotes

uncertainty : the sense of responsibility continues

;

and the temptation to seek relief in the artificial

irresponsibility of alcoholic euphoria is apt to become

irresistible. Financial worry was well illustrated in a

patient who, during the first three quarters of the

present year (191 1), has several times entered the

sanatorium. He had made a comfortable competence

in business and retired. But idleness bored him,

and he occupied his time in Stock Exchange specula-

tions. In ordinary years his operations would

probably have resulted in moderate profits—certainly

they were not such as would have led to serious

losses. But during the present year the markets

have admittedly been abnormal ; and everything he

touched went down. Insomnia followed, and for

the insomnia he took whisky, the dose of whichquickly rose, so that soon he became an intermittent

inebriate. Each fall in prices was succeeded by an

outbreak of drinking. And by watching the daily

quotations, it became possible to predict roughly the

day when this patient would again telephone for a

room in the sanatorium.

Worry takes many forms. The nagging wife has

become proverbial, and certainly she is a serious

obstacle when mated to one having a tendency to

alcoholism. But though less frequently heard of,

there are not a few nagging husbands whose influence

on their partners is equally unfortunate. Jealousy,

WORRY : JEALOUSY 17

when entirely causeless, is a well-recognised symptomof alcoholism ; hut with or without cause, it is a

potent source of worry, and consequently an exciting

or accentuating factor. Though included amongst the

extrinsic factors, worry, of course, depends very

largely, if not mainly, on the temperament of

the individual affected. Many seem to discover

sources of worry in every occurrence which in the

slightest degree departs from the usual. One asth-

matic and neurotic patient has returned several times

to the sanatorium, and on each occasion has given

what to him was a clear and valid excuse for his

relapse into alcoholism. On the first occasion his

wife had not been well—her indisposition wasobviously trivial : on the second, his little girl had

contracted chickenpox : on the third, his coachman

had given notice, and so on. But there is no doubt

whatever that, whether of adequate or inadequate

causation, worry is the commonest and most efficient

of all the exciting factors of alcoholism : its continu-

ance is the most frequent obstacle to success in

treatment, and the most frequent cause of relapse

after successful treatment. The subject will be again

referred to in the chapter on treatment.

Closely allied to, if not identical with, worry, is

any sudden increase of responsibility, even whensuch increase involves an improvement in financial

and social position. Many patients date their

inebriety from the death or illness of a superior

leading to promotion. Several secondary factors

may here be involved. The common mental con-

dition termed " swelled head " may be mainly

operative, or it may be the merely increased

2

l8 ON ALCOHOLISM

responsibility combined with additional work.

Overwork has determined many cases. Whenfagged with long hours a dose of alcohol un-

doubtedly acts as a stimulant, and enables the

worker—whether physical or mental, especially the

latter—to make a fresh start, or continue for a

longer time. Such stimulation, however, is short-

lived, and quickly succeeded by some slight degree

of narcosis which damages the quality of the work

even when the total output is increased. For

tiding over an emergency of work, tea, coffee and

strychnine are preferable, since their stimulant

effects are much more lasting, and are not followed

by any narcotic reaction.

In many cases inebriety has been determined by

sudden accession to fortune and independence, obviating

the necessity for further work. And in a very large

number retirement from business has led to the sameresult. Boredom in both cases has, of course, been

the chief psychological influence. The strenuous

man of business who for many years has beenpleasurably anticipating the time when he will beable to drop his harness with a clear conscience,

rarely foresees how little pleasure he will obtain

therefrom : he too often overlooks the risks he will

run. Almost equally with the successful performanceofwork, the satisfactory enjoyment of leisure demandsa preliminary training. And that man is supremelywise who, when contemplating retirement, provideshimself with one or more hobbies. It is futile todeny that to the great mass of human beingsalcoholic euphoria is pleasurable. But it is asource of pleasure from which the inebriate, or

INFLUENCE OF OCCUPATION IO

potential inebriate, is of necessity cut off. Both

must look round for compensations, of which there

are plenty. And many of the most permanent" cures " have been in those who have been fortunate

enough to acquire an absorbing hobby.

As is well known, certain professions and occupa-

tions yield a disproportionately large number of

inebriates. Many of these professions act by greatly

increasing accessibility. It is obvious that in publicans,

barmaids and potmen, continued accessibility is the

chief factor. So potent and certain is the influence

of accessibility that some of the chief life assurance

societies will not accept, even with heavy loading,

proponents who are employed in the retail liquor

trade. Wine and spirit merchants must be added to

the list. Commercial travellers also are continually

exposed to extra temptations through continual

change of residence and continual renewal of

business acquaintanceships. For long years it

has been an axiom that to be successful as a

" traveller " it is essential for a man to drink.

But during the last decade, at any rate, there has

been a marked change in this view. In many" lines " an abstaining traveller is now a success

where previously he would have obtained but little

custom. As might be anticipated, the traveller in

wines and spirits is the most hard pressed of all

travellers to remain temperate.

The stage supplies many victims to inebriety. Nodoubt in the lower or junior grades of stage life con-

stant accessibility to intoxicants is above the average.

But other factors enter largely into the result. Most

businesses and professions demand the cultivation

20 ON ALCOHOLISM

of self-restraint and the reasoning faculties ; and

advancement as a rule is to a great extent propor-

tionate to the success of such cultivation. The

emotions generally are at a discount. But in the

theatrical profession (also perhaps in music, and

some other branches of art) a relatively higher pre-

mium accrues from the cultivation of the emotions.

And it can hardly be disputed that the successful

cultivation of the emotional faculties is largely incon-

sistent with the successful cultivation— even the

retention—of the faculties of self-control or mental

inhibition.

The Stock Exchange has sent quite a few patients

to the sanatorium. As might be expected, the cases

have not been drawn as a rule from amongst the

most successful brokers or jobbers. Many factors

co-operate here owing to the extreme irregularity of

the routine of work. During a slack market there is

boredom and probably worry : there are long periods

during which the ordinary broker or small jobber

may not make his office expenses. During boomtimes there are intense excitement and extreme

overwork—very long hours. And the climax of

alcoholism or complete breakdown may be reached

at either period in accordance with the varying

temperaments of patients. In both, however—but

especially, I think, in those who break down duringan excited market—the commonest immediate ante-

cedent has been severe insomnia.

Almost the same may be said of the racing

fraternity.

Life in the tropics is supposed to be especially proneto induce habits of intemperance ; and certainly a

BOREDOM 21

disproportionate number of patients admitted to the

sanatorium have passed many years in the tropical or

sub-tropical dependencies of the Empire. Lassitude

resulting from prolonged heat no doubt predisposes

to frequent alcoholic stimulation. Crothers points

out that in America, " the hot waves which follow

each other during the summer months register their

duration and intensity in the police-courts, station-

houses and hospitals of all large cities by the sudden

increased number of inebriates who come under

observation." But probably a factor equally im-

portant with heat is boredom from lack of the social

amenities. It is noticeable that new settlements

which have not yet attained the stage in which the

wives and families of the residents become a part of

the community are especially prolific in cases of ine-

briety. In such, no doubt, many factors co-operate.

Considerations of this kind should demonstrate the

futility of sending patients to the Colonies and pro-

viding them while there with an allowance. In all

the over-seas states the " remittance man " is well

known, and always regarded as the most hopeless

type of inebriate.

Early training has naturally a bearing upon

alcoholism in after-life. Some of the worst cases

admitted had been brought up to take beer or claret

with meals. This, however, is found mainly in the

histories of patients of somewhat advanced age ; it

is rarer in the present generation.

Example operates in many ways. One of the

saddest cases of pseudo-dipsomania admitted was in

a young widow

:

22 ON ALCOHOLISM

She had been brought up a strict abstainer, and had

remained so until after her marriage. Her husband was a

chronic alcoholist, and during their first year of married life

the two had usually dined together at a restaurant. There

champagne was always called for, and the wife's first

experience of any kind of alcohol was dictated by the

sincere wish to prevent her husband taking too much.

Within a very few months, however, she had herself

developed severe inebriety.

Temperance reformers lay much stress upon the

influence of good examples : for the most part they

consider it a duty to remain or become abstainers so

as to lead the way and induce others to follow. But

without detracting in the slightest from the altruism

of these motives, it may be questioned whether a

large measure of success results from the practice.

The inebriate, at any rate, invariably argues that

there can be no credit in abstinence where temptation

is absent. And it is not easy to contradict him.

Be that as it may, it is certain that in many cases

the influence for good of a bad example is more

potent than that of a good one. This is demon-strated in many ways, but most strikingly in jthe

family histories of patients. One of the commonest of

all family histories shows a spurious atavism. Thepatient's father had been a life-long abstainer ;^but

on further inquiry it comes out that the paternal

grandfather had been an inebriate. No doubt the

father of the patient inherited the inebriate proclivi-

ties, but was saved from the consequences thereof

by the early warning of a drunken parent. Thepatient himself, inheriting the same proclivity,

succumbs thereto through the absence of any

INTRINSIC FACTORS 23

adequate warning example. At least, that is howthese histories appeal to me.

Intrinsic Factors.

Most of the intrinsic exciting factors of inebriety

depend on the employment of alcohol under medical

advice or otherwise for pathological conditions.

Such are manifestly numerous and extremely varied ;

and any attempt at a comprehensive list is precluded

by lack of time and space. Reference will be made

here only to those which have appeared prominently

in the clinical histories of patients admitted into and

treated in the Norwood sanatorium.

The pathological conditions for which alcohol is

given might be classified variously. But perhaps

the most useful classification clinically is into (i)

acute and (2) chronic and recurrent. For it may be

laid down as a general rule, to which there are very

few exceptions, that from the standpoint of the

initiation of the alcoholic habit, the medicinal use ot

alcohol is dangerous in proportion to the chronicity

or frequency of the ailment for which the drug is

prescribed. The same is admittedly true of other

drugs, such as morphine and cocaine. The two

classes, however, cannot be sharply defined : they

shade imperceptibly into each other.

Pyrexial conditions.—These are the most important

of the acute pathological conditions for which alcohol

in some form has been largely prescribed. A number

of patients have dated the commencement of their

habit from the medicinal use of the drug in typhoid,

acute dysentery, malaria, influenza, septic abortion, etc.,

24 ON ALCOHOLISM

or from the period of more or less prolonged

convalescence which followed these diseases. Not

so many years ago alcohol was very freely used

during the pyrexial stage of typhoid : it was regarded,

not, perhaps, as a specific, but certainly as all but

essential to avert the tendency to circulatory failure

which is the chief source of danger to life in the later

stages. I have, myself, been fortunate in having a

very extended practical experience of typhoid, and

my experience covers a part of the time when alcohol

in massive doses was the fashion.

I was in charge of the fever department of the

Brisbane Hospital (Queensland) from 1885 until

1891. During the first eighteen months of this

period I treated some six or seven hundred cases of

typhoid by the ordinary expectant method, giving

alcohol in the form of brandy or whisky, rather

frequently, and in some cases very freely—to the

extent of 8, 12, 16 or even more fluid ounces in the

twenty-four hours—whenever it seemed necessary,

as was then the custom. The chief indication wasthe condition of the heart and pulse. Economicalconsiderations, however, precluded the use of alcohol

except for the purpose of saving life : it was never

given as a luxury or placebo. Consequently its

use was always abandoned towards the end of the

febrile stage, that is, well before convalescence hadcommenced. Used with these limitations, it wasthe decided opinion of all connected with the fever

wards—visiting staff, house physicians, sisters andnurses—that alcohol never led to inebriety. Indeed,

it was commonly remarked that the effect wasrather to set up a distaste for alcohol—certainly

TYPHOID FEVER AND CONVALESCENCE 25

a distaste for that particular form of alcohol that

had been administered during the illness.*

Impressed with these memories, I have for over

six years carefully questioned all those sanatorium

patients who have ascribed their alcoholism to the

medicinal use of alcohol during an attack of febrile

illness, and I find that, without exception, the

alcohol has been continued into—usually well into,

and often beyond—the convalescent stage. In not

a few, wine, stout, etc., have been prescribed for

the first time during retarded convalescence. Thefollowing is a marked example

:

A retired sergeant-major in the foot-guards had always

been abstemious in his habits, though not an abstainer, until

he contracted dysentery in South Africa. His illness was

severe, and entailed his being kept in bed for five months.

During the whole of this time, he states that he lived mainly, if

* On January 1st, 1887, the treatment of typhoid by means of

systematic cold bathing according to the method of Brand wasintroduced, and this plan has been carried out practically without

interruption and with but few modifications up to the present day

:

my own superintendence ended in 1891, and between the above twodates some 1400 cases were treated. Amongst the many favourable

changes which were observed to accrue from the change in the

routine treatment, the fall in the amount of alcohol consumed was

prominent. At the end of the first twelve months of systematic

bathing it was seen that the alcohol bill for the fever wards had been

reduced by at least three quarters. And this saving had not been due

to any sudden change of opinion as to the value of alcohol in pyrexia :

it had followed naturally through the rarity with which the circulatory

symptoms, which were then supposed to call for alcohol, had arisen.

In fact, after the introduction of cold bathing, the indications for the

use of alcohol underwent a complete change. Previously it had

been given to sustain the heart's action. Thereafter it was used for

its vaso-dilative influence—to modify the vaso-constriction of the

cutaneous area, and so to relieve shivering, and at the same time

promote the abstraction of heat by the bath. (See ' The Cold-bath

Treatment of Typhoid,' by Francis Hare: Macmillan & Co. 1898.)

26 ON ALCOHOLISM

not solely, on beaten-up eggs with either brandy or port

wine. Ever since his convalescence he has been a pseudo-

dipsomaniac, that is to say, he has been unable to touch

alcohol in any form, even a glass of light beer, without

immediately plunging into a heavy drinking bout.

It would appear that alcoholic euphoria—which is

of course the only dangerous effect of alcohol from

the standpoint of starting inebriety—is largely incon-

sistent with the existence of pyrexia, at any rate,

acute pyrexia : I have never known the typhoid

patient resent or even regret the stoppage of his

whisky or brandy. Here, too, may be appropriately

recalled the observation made by many, both

physicians and patients, that during an attack of

pyrexia, even a mere feverish cold, the desire for,

and enjoyment of, some accustomed alcoholic drink,

remains in complete abeyance for the time being.

The same seems to be true, though to a much less

extent, of some other narcotic drugs.

It is certain, however, that any antagonism whichexists between alcoholic euphoria and pyrexia

vanishes promptly at convalescence. Then andthenceforward for a time there is probably anexaggerated appreciation of alcoholic euphoria, andconsequently an exaggerated danger of initiating

the alcoholic habit. The special factors whichduring convalescence conduce to this increaseddanger are physical weakness and mental depression.

Physical weakness of some kind is common to theconvalescent stage of practically all fevers; andwhen associated with anaemia, and especiallyabsence of appetite, is the usual reason for theprescription of alcohol by the physician. The

ANAEMIA : DEBILITY : MENTAL DEPRESSION Z'J

danger of such prescription is, of course, intensified

in fevers, such as malaria and dysentery, which are

liable to become frequently recurrent, or to taper

off into chronic sequelae. His convalescence being

tedious, the patient frets to resume his work, and

the stimulant action of alcohol enables him to start

in this direction. Unfortunately such stimulation

is evanescent, and does not enable him to continue

unless it is frequently repeated. Hence the imminent

danger of starting chronic alcoholism. A high pro-

portion of those who have entered the sanatorium

have been resident in the tropics, and a majority of

these have ascribed their habit to the prescription

of alcohol in the debility and anaemia following

malaria and dysentery, and to the continued use

of alcohol in some form to enable them to resume

work before they had fully recovered their strength.

In women, the commonest pyrexial condition

which has been blamed for the commencement of

inebriety is septic abortion or puerperal fever of

some kind. Here, again, it is obviously the use of

alcohol during the pain and discomfort of prolonged

and often incomplete convalescence which has been

mainly operative : its use during the sharp and severe

pyrexia itself would have been immaterial. And in

most of these cases, the medicinal use of alcohol has

passed by insensible gradations, but uninterruptedly,

into chronic alcoholism : there has rarely been any

intermediate stage.

Mental depression as a symptom of convalescence

from fevers generally does not seem to be of very

common occurrence. But exceptions must certainly

be made in the case of influenza in this country, and

28 ON ALCOHOLISM

of dengue in some parts of the tropics and subtropics

:

in the early convalescent period of both, some degree

of mental depression is the rule rather than the

exception. That which follows dengue is much the

more severe, and has ended not very rarely in suicide.

Both varieties have frequently initiated the alcoholic

habit ; and both almost invariably cause a gross

exaggeration in the severity of an already existent

alcoholism. A few cases have been admitted in

which the history showed that post-dengue de-

pression had been a factor in the past; but naturally

the post-influenzal form is that which has almost

exclusively come under notice at the sanatorium.

Post-influenzal depression lasts as a rule but a few

days, and ceases somewhat suddenly : usually it is

not severe. No doubt for those who are normally

constituted it is of small importance, and is soon

forgotten. But for all those (whether they are

abstainers or not) who have already acquired an

undue appreciation of alcoholic euphoria—who, in

other words, have a vivid realisation of the immediate

relief from depression which a large dose of alcohol

is capable of affording—the convalescent stage of

influenza is apt to be an event of grievous con-

sequence. It constitutes a special and urgentdemand for euphoria; and unfortunately it is a

demand which comes at a time when the power ofself-control is below the normal. Hence in thehistories of alcoholists attacks of influenza havefrequently marked fresh starting-points on thedownward journey of alcoholism. And they prove,moreover, to be amongst the commonest of theintrinsic exciting factors of relapse in those who

INSANITY 29

have long been abstainers. Some persons have

annual or biennial attacks of influenza, and such,

if inclined to alcoholism, are especially unfortunate.

Much more potent as a class than the acute are

the chronic and recurrent morbid conditions which are

found to act as exciting factors of inebriety. Theyare also more numerous, and, being extremely varied,

are difficult to classify.

Insanity.—Insanity or incipient insanity may be a

cause or a result of inebriety. Until lately it wasregarded as a common result. Quite recently, how-

ever, this has been questioned, and the present

tendency is to consider the inebriety which is

associated with insanity as very frequently an early

symptom or manifestation of the oncoming mental

disorder (Mott).

During the last 6h years at the Norwood Sana-

torium there have been 762 admissions under the

head of alcoholism ; and of these 23 have been

mentally unsound. Most of the 23 were sent into

the sanatorium under a misapprehension. Either

the mental symptoms were ascribed to the direct

effect of alcohol, that is to say, the symptoms of

insanity were mistaken for the symptoms of drunk-

enness— this was rare, however; or the mental

symptoms were recognised as an indication of an

insane condition, but this insane condition ascribed

to alcoholism. Of course, in all cases, the mental

disorder was regarded as temporary, and likely to

subside rapidly under the influence of abstinence.

Yet observation after admission led to the conclu-

sion that in only 5 of the 23 cases could the mental

condition be ascribed to alcoholism. One of these

30 ON ALCOHOLISM

was a case of true periodic dipsomania, in which the

cessation of each paroxysm was followed by acute

melancholia lasting some weeks : this led eventually

to suicide. Another, a case of polyneuritic psychosis,

or Korsakow's disease, which began with the symp-

toms of delirium tremens. Yet another, a case

which can only be regarded as chronic delirium

tremens, or chronic alcoholic delirium, which re-

covered after some weeks in the sanatorium : here

there was no polyneuritis, yet the mental condition

was similar to that which may be observed in

Korsakow's disease. In the other two of the five the

mental symptoms did not amount to more than mild

dementia, which appeared to depend mainly upon

loss of memory.

In the remaining 18 cases there was little doubt

that the inebriety constituted an early symptom of

oncoming insanity, and was not causative. Amongstthese were 2 cases of general paralysis, 2 of melan-

cholia, 1 of severe hypochondriasis, and 1 of dementia,

while 12 were cases of mild delusional insanity. Ondiagnosis, the majority were transferred from the

sanatorium to other institutions.

A bnormal mental conditions not amounting to insanity.

—All the twenty-three cases included under the head

of insanity were certifiable. A considerable number of

patients, however, have been admitted in whomabnormal mental conditions, short of certifiable in-

sanity, have certainly acted as exciting factors of

inebriety. These may be referred to generally as

borderland cases, psychasthenics, etc. In each usually

some one special symptom was prominent. Claus-trophobia (fear of being shut in some small place)

CLAUSTROPHOBIA : AGORAPHOBIA 31

seems especially common. Many patients complained

of being quite unable to travel by train without pre-

viously taking a large dose of alcohol. In some of

these the objection was only to the small transverse

railway compartment : a corridor carriage put them

quite at ease. In others, the symptom was absent if

the patient was accompanied by an acquaintance or

even a stranger. The opposite phobia, namely,

agoraphobia, also appears amongst the exciting

factors, but seems to be less common. Here, also,

alcohol in adequate doses has proved capable of

abolishing the symptom for the time being. In one

very marked case (described on p. 52), persistent

agoraphobia was clearly the chief factor in the pro-

duction of chronic alcoholism.

Ordinary shyness may amount to a mental disorder.

And it is a psychical weakness which enters into the

production of alcoholism and inebriety to a far

greater extent than is generally realised. Those

who have never suffered from it have no conception

of the mental torture—I use the word advisedly

—

for which shyness may be responsible in certain

emergencies and critical periods in the life of those

who are so afflicted : I know of one instance in which

a rather public breakdown due solely to shyness led

to an undoubtedly serious and nearly successful

attempt at self-destruction. Unfortunately for the

shy, alcohol, and indeed narcotic drugs of almost

any kind, can be absolutely relied upon to remove

this seemingly ridiculous weakness for the time being.

And perhaps, too, it is unfortunate that shyness—in

common with affections such as sea-sickness and

toothache—does not arouse much real sympathy in

32 ON ALCOHOLISM

others : the humorous aspect is too conspicuous.

" Pulpit," " stage," and " speech " fright are special

varieties of shyness; and all have been the chief

exciting factors in different cases of alcoholism.

Only a few months ago the subject of "speech

fright " evoked an epistolary discussion in one of the

weekly medical journals, and one of the contributors

seriously suggested as a preventive the taking of a

small dose of laudanum just before the time when

the sufferer would be called upon to speak. There

is no doubt as to the immediate efficiency of the

drug in these circumstances. But could any more

certain means be devised of starting the opium

habit ? I know of none.

Mental depression. — Usually recurrent, even

periodic, in its manifestation, but sometimes more

or less continuous, mental depression is a very

common asserted factor of inebriety. Two of the

conditions under which it arises, namely, the early

convalescent stages of influenza and dengue fever,

have been considered already (p. 27). But referring

only to patients admitted into the sanatorium, it has

occurred also as a premonitory symptom of insanity,

as a result of tobacco amblyopia, tabes, change of

occupation involving loss of accustomed physical

exercise, long-continued eye-strain, as a symptom of

" suppressed gout," and of recurring or persistent

high blood-pressure, as a sequela of morphinism andoutbursts of dipsomania and pseudo-dipsomania, as

a post-epileptic phenomenon, during the menopause,

and in connection with menstruation, and from no

known cause. Only a few of these factors require

special notice.

MENTAL DEPRESSION 33

Mental depression occurring in connection with

menstruation is extremely common amongst female

inebriates. In the great majority of those in whomit occurs it begins during the two days preceding the

commencement of the flow. In some it commencesduring the flow, and in some others just after its

termination. This menstrual incidence of mental

depression has not been explained. But there are

many analogous happenings. Periodic insanity is

very prone to occur just before menstruation, as also

are hysterical attacks. And it is not difficult to

show that during the pre-menstrual period in many—perhaps the majority of—women, there is a

psychical alteration, which, however, by no meansalways takes the form of depression ; often there is

restlessness, a craving for physical exercise, or, on

the other hand, a longing for physical rest—the

latter less frequently, however. The psychical andgeneral symptoms of menstruation have, I think,

best been collated in an important article by

Dr. Helen McMurchy.*This mental alteration undoubtedly explains the

frequency of what is known as menstrual dipsomania.

It is difficult to be sure that outbursts of inebriety

occurring at the menstrual period should be classed

as pure dipsomania—that they fully coincide with

the definition of that disorder to be given later (p. 61).

But there is no doubt that in a certain proportion of

such cases there is no desire for alcohol during the

intermenstrual epoch, and therefore no difficulty in

abstaining ; whereas the immediately pre-menstrual

stage regularly brings with it an almost uncon-

* ' Lancet,' October 5th, 1901.

3

34 ON ALCOHOLISM

trollable impulse to indulge to excess. It is usual in

this disorder to search for disease of the internal

genitalia, but it is certain that even in the worst

examples the uterus and its appendages may be, and

usually are, macroscopically healthy. Moreover,

when they are otherwise, it rarely happens that

surgical interference (short of complete ablation of

the appendages, which is not, of course, to be

recommended) exerts any beneficial effect upon the

recurring paroxysms.

Probably it is the nervous or vaso-motor mechanism

of menstruation which is at fault. Blood-pressure

observations during menstruation in normal womenare few, but the most recent do not show a constant

variation.* On the other hand, " Rosse found that

hysterical girls who complained of pain and other

abnormal sensations during menstruation had a

steady rise of 20 mm. Hg. during the flow, instead

of normal or diminished pressure."t My ownobservations in cases of menstrual dipsomania so far

as they go tend to show that during the immediately

pre-menstrual stage there is a decided rise of blood-

pressure, and that such rise coincides pretty

accurately with the psychical alteration responsible

for the dipsomaniac outbreak. Numerous observa-

tions, however, are required before this conclusion

can be definitely accepted.

In the following case, the observations connect the

pre-menstrual blood-pressure variation with the pre-

menstrual mental depression very clearly. Morningand evening observations were taken regularly, so

* 'Clinical Study of Blood-pressure,' Janeway, 1907, p. 127.

t Ibid., 257.

PRE-MENSTRUAL DEPRESSION 35

as to cover two menstrual periods. The patient wasa single woman, aged 44 years. Her outbreaks of

drunkenness were associated with, and obviously

depended on, marked mental depression ; they began

as a rule three days before the commencement of

menstruation, which was of somewhat irregular

occurrence. They lasted two days only, both the

depression and drinking ceasing suddenly one com-

plete day or sometimes more before the commence-ment of the flow. The subjoined chart shows this

clearly :

—

December /908 Je.nua.ri/ I9Q9Date 22 23 24 25 26 27 26 29 30 31

160

150

140

130

I 20

I 10

IOO

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The association of increased blood-pressure with

mental depression is not restricted to the menstrual

period. Mental depression occurs in connection

with the persistent high blood-pressure of middle and old

36 ON ALCOHOLISM

age, as pointed out by Broadbent* ; and the most

successful line of treatment is such as tends to relieve

the circulatory disorder.

Mental depression occurring at the menopause is

well recognised in the domain of psychological

medicine; it seems especially frequent in patients

who have long suffered from pre-menstrual or

menstrual attacks of depression. And in several

cases admitted into the sanatorium severe climacteric

inebriety has set in concurrently. It is customary

—

and certainly expedient—in such cases to hold out

the hope that when the " change of life " has been

completed there will be a great change for the

better in all respects. And as a rule, it may be said

that the climacteric mental depression is tempo-

rary, ceasing with the complete cessation of ovarian

activity. Unfortunately, however, it does not

always happen that the inebriety disappears sim-

ultaneously : this is, of course, especially true of

those in whom the climacteric involution is pro-

longed. But it may, I think, be said of patients

whose inebriety can be clearly traced to the meno-pause, that their chance of ultimate recovery is

distinctly better than that of males of the sameage suffering from inebriety of equal severity andduration.

Post-epileptic mental depression accounted for

numerous outbreaks of inebriety in one patient

admitted into the sanatorium.

The patient was a medical student, aged 32 years. Hisepileptic attacks began at the age of twenty-one after he hadbeen working hard for one of his examinations. They were

* 'The Pulse,' 1890, pp. 177, 304.

PERIODIC DEPRESSION 37

for the most part atypical. His early seizures were of the

nature of prolonged petit mat : they would begin without

apparent cause, and consisted chiefly of giddiness and severe

nervousness, lasting about fifteen minutes, and leaving himfrightened and low spirited. Later they approximated to

major epilepsy in character, and his tongue was injured onseveral occasions. He had some forty or fifty in all during

twelve years. At the age of twenty-three the post-convulsive

depression became more marked and prolonged, and thence-

forward he acquired the habit of taking large quantities of

whisky for relief. At other times he drank but little, andhad no temptation to exceed.

I have been unable to follow up this case.

It remains to consider recurring or periodic

attacks of mental depression without apparent cause,

at any rate without causes generally accepted by

the medical profession. I am not here referring to

cases of true dipsomania, the outbreaks of which

affection often commence with mental depression

:

dipsomania will be considered later. But manypersons suffer at regular or irregular intervals from

attacks of " the blues," which they are quite at a

loss to explain, and which not rarely underlie a

severe intermittent form of inebriety.

There is a mental depression, usually associated

with, or leading to, a form of insomnia, which tends

to recur daily in the small hours, between two and

five or six a.m. The rate of combustion rises and

falls rhythmically throughout the diurnal cycle, in

accordance with the varying demand for force and

heat production, and the period referred to corre-

sponds, except in night workers, to the lowest rate of

combustion (and to the lowest body temperature) in

38 ON ALCOHOLISM

the twenty-four hours.* It is at this time that

asthma, angina pectoris, gout, some headaches and

many other nervous disorders are especially prone

to recur, and it is then that death most commonlytakes place. Probably the same recurring fluctuation

in combustion is at the bottom of the mental

depression which regularly wakes some patients at

this period of the day, and which occasionally

starts, but more frequently exaggerates, alcoholism.

The tendency may be largely modified or abolished

by refraining from food late in the evening, and by

taking physical exercise between the last meal of the

day and bedtime, f as in the following case :

Case of Nocturnal Mental Depression.

A clergyman, aged 63 years, though not an abstainer, hadall

his life been abstemious, or moderately so, until the last few

years, during which he had suffered from a peculiar form of

insomnia. He rarely found any difficulty in going to sleep :

indeed, he habitually fell asleep almost at once on lying

down. But during the last two years he had contracted

the habit of waking every morning almost exactly at 2.30,

whenceforward, unless he took alcohol, he would lie awakeuntil 7 or 8 a.m. Moreover, immediately on waking he

would be in a state of great mental depression, whichwould, however, slowly subside ; and he had come to the

conclusion that it was the cerebral condition responsible

for his depression, which actually woke him. Before

admission he had been treated on and off unsuccessfully

for about a year. After admission, total abstinence andseveral drugs were tried without result. He was then

directed to make his chief meal at 1 p.m., to take a very

* ' The Food Factor in Disease,' Francis Hare, 1905, vol. i, p. 95et stq.

t Op. cit., vol. i, p. 227 et seq.

RECURRING HIGH BLOOD-PRESSURE 39

light dinner in the evening at 7, and to interpose between

this meal and bedtime a considerable amount of walking

exercise. The night following the change in his habits he

slept uninterruptedly throughout, and this continued. Six

months later he had had no return of his special trouble

and remained an abstainer.

It is to be remarked that it was the depression which

induced him to enter the Sanatorium. Simple insomnia

he would have put up with, as he was a man of ample

leisure, and, as he said, could always read during the night,

and sleep during the forenoon, if necessary.

Some attacks of mental depression are coincident

with, if not dependent on, recurring attacks of high

blood-pressure. The following case—one amongst

three or four admitted—is typical of this small

class

:

A business man, aged 49 years, had suffered for some four

or five years from obscure and indescribable nervous attacks

lasting several days. After a period of mental comfort and

good health of variable duration, he would be seized (usually

in the morning on waking) with a feeling of oppression in

the head, hardly amounting to an ache : coincidently he

would be nervous, excitable, and mentally depressed. Then

he would often be driven to take alcohol in the endeavour

to obtain relief. If he took spirits he would quickly

become almost maniacal and dangerous both to himself

and others, though not always simultaneously. He had

attempted his life more than once, though there is some

doubt whether such attempts were quite serious ; also he

had made violent assaults on others, even those to whomhe was much attached, and it is certain that some of these

might have resulted very seriously. During the whole

attack he would suffer severely from insomnia, which

necessitated hypnotics every night.

Warned by the effects of spirits, he had for two years

40 ON ALCOHOLISM

limited his alcoholic intake during attacks to bottled ale.

Even ale, however, and that in but moderate quantity,

would render him practically irresponsible, and his family

would be forced to send him back frequently to the Sana-

torium. While in the sanatorium his " head " attacks

continued to recur, but on no occasion had they led to his

taking alcohol.

He was examined for eye-strain. There was some hyper-

metropic astigmatism, but correction of the error proved

ineffectual for relief.

Finally a series of observations on his blood-pressure

was made. It was found that during his intervals of mental

comfort his maximum systolic blood-pressure varied from

126 to 138 mm. Hg; but that when "suffering with his

head" it would usually be over 150 mm. Hg. Further,

there was a direct relation between the severity of his

attacks and the height of his blood-pressure : during one of

his worst the pressure attained 164 mm. Hg.

He was treated as for persistent high blood-pressure.

Potassium iodide in five-grain doses was given thrice daily,

and calomel (2 grains) twice weekly. He was also dieted.

Meat, fish and eggs, one or all at each of his three meals

;

green, non-starchy vegetables ad lib. ; and his carbohydrate

intake reduced to from three to five ounces per diem, i. e. to

the lowest point which experiment showed to be consistent

with the maintenance of his body-weight. Regular but

moderate physical exercise was enjoined.

The above treatment was carried out consistently for

three months. His attacks ceased, no hypnotics were

required, and his blood-pressure kept for the most part

between 126 and 136 mm. Hg. On two occasions it rose

to 140 and 142 mm. Hg. respectively, associated with very

slight depression : this was when he had become a little

careless in carrying out instructions. But on the whole hehad enjoyed better health, mental and physical, than for

the previous half-dozen years.

INSOMNIA 41

Change of occupation involving the loss of accus-

tomed physical exercise has led to attacks of mental

depression and consequent inebriety in several cases

admitted. In the following case such causation

was clearly established :

A University graduate, aged 25 years, entered his father's

office, in which the hours were long. Practically the only

exercise he then had was in walking between his home and

the office morning and evening. Previously he had led a

very active outdoor life and was well known in athletic

circles. He was of a lean and muscular habit, and showed

no tendency to accumulate fat, as is so often the case with

athletes on giving up exercise. Instead, he soon began

to suffer from mental depression. This led to serious

outbreaks of inebriety and to his admission into the

sanatorium.

While in the sanatorium he spent most of the day rinking

in the Crystal Palace, and all depression quickly vanished.

Moreover, it was found that each individual attack of

depression could be completely dispersed by any form of

muscular exercise lasting about an hour. He was advised

to give up office work, which fortunately he was in a

position to do. On leaving he was employed in outdoor

work connected with his father's business, and the result

was entirely satisfactory : both his depression and inebriety

ceased. Twelve months later he remained well in all

respects.

Insomnia.—Insomnia is a very common exciting

factor of inebriety. The following is a typical

case

:

A married man of means and no occupation, aged 37 years,

had suffered from many outbreaks of inebriety, which might

be described as gradually commencing and rather prolonged

attacks of pseudo-dipsomania {vide p. 71). During his

42 ON ALCOHOLISM

intervals he was an abstainer, and all his outbursts started

in the same way. After a period of abstinence he would,

usually in consequence of some slight domestic worry, but

sometimes from no known cause, begin to suffer from

insomnia. A little wine at his late dinner, with a single

" night-cap " of spirits, would set him quite right as regards

sleep. But he would have to continue this indulgence.

Nevertheless, he found no difficulty in avoiding any material

increase for two or three months. But at the end of that

period he would commence to experience a compelling

and continuous craving for alcohol, which, unless he

quickly entered the sanatorium, inevitably developed into

a typical outburst of pseudo-dipsomania.

Debilitating conditions.—Any chronic affection

leading to, or associated with, ancemia or physical

or nervous debility may eventuate in inebriety if

alcohol in any form is prescribed by the physician

as part of a scheme of diet. The result will be

determined by the existence or the reverse of the

predisposing causes in the patient. Naturally, the

large majority of such patients escape the formation

of the alcoholic habit. But apart from a well-marked

family history of alcoholism or other drug habits

—

which is by no means always present, and even whenpresent, not invariably a sign of special danger

—

there is no guide whereby it is possible to dis-

criminate in advance between patients for whomalcohol is specially dangerous and those for whomit may be prescribed with comparative safety. It is

better, therefore, to avoid alcohol in any of its well-

known forms. In the few cases in which it is sup-

posed to be specially indicated, it can always beprescribed as a mixture in which its taste is more

PROLONGED LACTATION 43

or less concealed by that of other drugs—such as

ammonia—of less pleasant flavour.

The prescription of port wine or stout for chlorosis

has been the commencement of the alcoholic habit

in four or five of the female patients admitted to the

sanatorium. In one very intractable case there had

been scoliosis also

:

The patient when a school-girl spent many months in the

supine position. Frequent generous meals were ordered,

and port wine given whenever appetite was deficient. The

wine was taken to readily. The less the appetite the more

wine was given to compensate. A port-wine habit was soon

established. At the time of her marriage, at the age of 28,

she was taking regularly eight glasses a day. After marriage

the amount steadily rose. She entered the sanatorium at

the age of 37. For two-and-a-half years previously she had

been taking considerably more than a bottle a day, with

other alcoholic drinks, and had frequently shown signs of

intoxication.

Prolonged lactation is stated to have led to inebriety

through the prolonged local irritation (Crothers). In

the sanatorium prolonged lactation was the starting-

point in two cases, but the steps in the acquirement

of the habit seem to have been debility, anaemia, and

emaciation. The physical condition in both seemed

to call for the prescription of stout. There is a

wide-spread belief amongst the older members of

the nursing sisterhood that stout above all else

"makes milk." Were this well based, it might

perhaps be justifiable to take some risk of inebriety

for the sake of a weakly infant. But in point of

fact there is no scientific basis for the belief. As

has often been pointed out, the fluid most helpful for

44 ON ALCOHOLISM

the nursing mother, both in her own and the infant's

interests, is milk—good fresh cow's milk. Prolonged

lactation as an exciting factor is much commoner

amongst the poor than in the class which frequents

the sanatorium.

Dyspepsia has been responsible for the commence-

ment of the alcoholic habit in some cases. Naturally

these have usually been those in which alcohol was

found to give relief from the gastric discomfort. Thefollowing is a case in point

:

A stockbroker, aged 41 years, had been a total abstainer

up to the age of thirty-two : this on account of a very clear

and marked hereditary tendency to alcoholic excess. Hethen became affected with almost constant dyspepsia.

Treatment of various kinds failed. Finally he consented

to take some alcohol with his meals. This gave complete

relief from the dyspepsia, and as a result he put on nearly

two stone in weight in three months. But he rapidly

became an inebriate, and remained so until after he had

been twice treated in the sanatorium.

In another case dyspeptic attacks led to exaggerated

drinking, and would certainly have prevented the

patient from remaining an abstainer had he not

been successfully treated.

The patient was a gentleman, aged 29 years, who hadbecome a chronic alcoholist since returning from the BoerWar. At times he took very large quantities of spirits in

a very short time and became intoxicated. This happenedwhenever he suffered acute gastric flatulence. The dis-

tension of the stomach induced severe palpitation andgreat irregularity of the heart's action, accompanied with

cold sweats and such terror that he hardly knew what he

DYSMENORRHEA 45

was doing at the time. The attacks continued to recur

occasionally for a time after he had ceased drinking, andwould have undoubtedly led to a relapse. Fortunately, it

was found that they could be completely prevented by

eating very slowly, and taking no liquid of any sort at meal

times or for an hour beforehand or subsequently.

On the other hand, several cases have occurred in

which an attack of dyspepsia has removed the wish

for alcohol for the time being.

Neurasthenia, in its numerous and varied manifes-

tations, is constantly advanced as a cause of alcoho-

lism, whether correctly so or not, is difficult to decide.

There is no doubt, however, that it is a very commonexcuse. And there is equally no doubt that it is a

fairly common result. Neurasthenia is almost im-

possible of definition. But neurasthenics pass by

insensible gradations into psychasthenics, psychas-

thenics into borderland cases, and these again into

cases of overt insanity. This subject is too wide to

be more than merely referred to here.

Recurrent or paroxysmal affections—for the most

part due to disorder in the vaso-motor nervous system

—such as dysmenorrhoea, asthma, periodic sick-head-

ache or migraine, paroxysmal tachycardia, neuralgia,

especially of the fifth, and sciatica, even functional

angina pectoris, and the paroxysms described by

Gowers as vaso-vaga^ have all proved exciting factors

of inebriety in cases admitted into the sanatorium.

Dysmenorrhoea.—This has proved the most fre-

quently operative in the above list. It is undoubted

that congestive dysmenorrhoea may be relieved or

abolished for the time being by an adequate dose of

alcohol, no matter what be the nature of the local

46 ON ALCOHOLISM

lesion (if any) discoverable on examination. Unfor-

tunately, too, the fact is widely known, and very

commonly taken advantage of, the usual form in

which alcohol is taken being hot gin and water.

To explain the anodyne influence of alcohol in

dysmenorrhoea it is necessary to recall and bear in

mind the mechanism of menstruation. The menstrual

flow—the oozing of blood from the mucous membraneof the uterus—depends directly upon a certain degree

of vascular distension in the uterine mucosa. This

vascular distension itself depends on three factors,

namely : (i) the force exerted by heart-beat : (2) the

dilated condition of the uterine arteries and arterioles

;

and (3) the undilated condition of the arteries in

other areas—in other words, the maintenance in the

aggregate of other vascular areas of the normal

degree of arterial tone or vaso-constriction. (It seems

probable, in some cases at least, that the general

arterial tone is actually somewhat increased during

menstruation.) All three factors are essential. It

follows that by modifying any one, we may modify

the vascular distension (congestion) of the uterine

mucosa. Alcohol is a vaso-dilator, and its adminis-

tration modifies the third factor—the general arterial

tone. Simultaneously, there is a decrease in the

menstrual flow, a decrease in the vascular distension

of the uterus, and relief, partial or complete, from the

pelvic and ovarian pain—of which pain, vascular dis-

tension or congestion is undoubtedly one essential

factor. But alcohol, though perhaps the most con-

venient, is by no means the best, of the vaso-dilators.

Even more efficient is the whole series of the nitrites.

Amyl nitrite, indeed, may be said to be too efficient,

ASTHMA 47

since as a rule it stops the menstrual flow completely,

for the time being at least : it should be avoided

except in cases of menorrhagia, and then used only

towards the natural end of the period. Nitro-glycerine

gives ample relief, but probably in the majority of

cases spiritus aetheris nitrosi is all that is required.

Asthma.—Paroxysms of asthma stand to inebriety

in precisely the same causative relation as attacks of

painful menstruation : they are less important only

because they are less frequent, and because the relief

from asthmatic dyspnoea which follows alcohol is

less common, and perhaps, as a rule, less complete.

But there are numerous cases of asthma in which

alcohol not only gives absolute relief, but was for a

long time the only known remedy which would do so

(Hyde Salter). I do not know how those physicians

explain this action of alcohol who still believe that

the obstructive dyspnoea of the complaint depends

upon constriction of the bronchioles by their owncircular muscle-fibres. But for those who, like my-self, hold a vaso-motor view, there is no difficulty

whatever. The vaso-motor view, however, must be

fully stated. Too often the obstructive swelling of

the bronchiolar mucosa is said simply to depend on

dilatation of the contained arterioles. This statement

is less than a half-truth, and helps the explanation

not at all. Even more obviously than is the case with

menstruation, the vascular distension (congestion or

swelling) of the mucous membrane in question

depends on three factors, namely— (i) the force

exerted by the heart-beat : (2) the dilated condition

of the bronchial arteries and arterioles ; and (3) the

undilated, or rather the exaggeratedly constricted con-

48 ON ALCOHOLISM

dition of the arteries in other areas, notably the

cutaneous area. (The smallness of the radial artery

during the asthmatic paroxysm and its enlargement

synchronously with the cessation of the paroxysm

was noted nearly half a century ago by Hyde Salter.)

As in dysmenorrhoea, so in asthma, modification of

any one of the three circulatory factors will modify

the distress of the affection ; but the factor modified

or removed by alcohol is in both cases undoubtedly

the same, namely, the undilated or constricted con-

dition of the arteries generally—these arteries are by

it promptly dilated. In the following case the action

of alcohol in asthma was well shown ; and it is diffi-

cult to see how any similar patient so treated could

possibly escape inebriety

:

A gentleman, aged 25 years, had suffered from asthma

practically since birth. At the age of eleven he was ordered

to take whiskey whenever a paroxysm occurred or even

threatened. The effect of whiskey was " magical ": a very

little would completely disperse all dyspnoea. He had

continued the same treatment ever since ; but as his

asthma attacks had been very frequent, so had his resorts to

whiskey. Moreover, he had soon found that to be efficient

the drug had to be taken in continually increasing doses.

On entering the sanatorium he had become a typical pseudo-

dipsomaniac. The history of each dipsomaniac outbreak

was as follows : an attack of asthma, a stiff glass of whiskey

giving instant relief: dipsomaniac craving and continued

heavy drinking until laid up with gastric catarrh and prostra-

tion. It was noteworthy that so long as he continued to

drink, no matter how ill he became, he suffered from no

trace of asthma. The asthma returned only after full

convalescence.

Did it act as a heart stimulant, as once was

RECURRENT NEURALGIAS 49

thought, alcohol could but increase the asthmatic

dyspnoea. Clearly its action is merely vaso-dilative,

and it is a pity that it should ever be used for this

purpose, since many other drugs, free from any

danger of setting up habits, are equally or more

efficient. In the case just cited nitro-glycerine acted

as promptly as whiskey.

Recurrent neuralgic and allied painful conditions.—These do not so frequently act as exciting factors

of alcoholism as of morphinism. Still, patients have

been admitted who have ascribed their alcoholic

habit to sciatica, neuralgia of the fifth, migraine and

functional angina pectoris respectively. It is note-

worthy.that in all these alcohol gave temporary relief

from the painful paroxysm, and was taken in the

first instance with this object. It is perhaps the

general rule that alcohol does give relief in such

cases, but there are certainly many exceptions,

especially in neuralgias affecting the face and head.

In many cases of neuralgia of the fifth and in manymigraines alcohol even in small doses markedly

increases the pain. This apparent inconsistency in

the action of alcohol has not been clearly explained.

Possibly it may be that in some cases the vaso-

dilative, in others the cardio-stimulant, action

preponderates.

In one instance—that of a lady suffering also from

slight mitral insufficiency

—

paroxysmal tachycardia

was the chief exciting factor of inebriety. And in one

other the paroxysm which led to the use of alcohol

was such as has been described by Gowers under

the title of vaso-vagal attacks. In both these cases

alcohol gave very marked relief.

4

50 ON ALCOHOLISM

Eye-strain.—Only during quite recent years has

eye-strain been brought prominently forward as a

common factor in functional disorders of the nervous

system. And the credit must, I think, be given

very largely to the persistent and enthusiastic

advocacy of Dr. George M. Gould, of Philadelphia.*

Gould contends that practically all migraines and

most headaches, numerous neuralgias and manydyspepsias, together with their associated symptoms,

especially insomnia and mental depression, besides

many other functional disorders of the nervous

system, even epilepsy in some cases, depend upon

the " loss of nerve force " which is occasioned by

the constant muscular effort needed to produce

clear vision in an eye that is optically faulty. Heconsiders that, if anything, he has under-stated the

importance of ametropia as a pathological factor.

His critics, on the other hand, have consistently

accused him of gross exaggeration.

I suggest that both are right. This seeming para-

dox is susceptible of explanation by the inefficiency

of the existing classification of disease—a classifica-

tion which, having no relation to causation, and

being merely anatomical or regional, is of necessity

artificial. It is certain that some migraines and

many ordinary headaches do depend fundamentally

upon errors of refraction, especially, perhaps, hyper-

metropia with astigmatism, and that such cases

can be fully relieved by accurate correction by glasses.

But it is equally certain that many more migraines

and headaches have no connection whatever with

the eyes : both, as Harry Campbell has pointed out,

* ' Biographic Clinics,' 1904, P. Blakiston & Sons.

EYE-STRAIN 51

occur at times in the blind. Herein Gould may be

charged with exaggeration. But he has also under-

stated his case. For it can be shown that manyfunctional disorders of the nervous system, other

than those enumerated by Gould, but which are

both clinically and pathologically nearly allied to

migraine, may also, in some cases, depend on

ametropia, and are then equally susceptible of relief

by accurate correction by glasses. Edward Liveing,*

writing so far back as 1873, refers to a case of

angina pectoris, in which the use of suitable glasses

put an end to the recurring paroxysms. Dys-

menorrhoea, referred to a few pages back as some-

times due to vaso-motor disorder, has been traced

in some cases by Howard Kelly.t Ernest Runge,J

and others to hypermetropia. Albert Fardon§ has

published a case in which enuresis was due to

the same optical error. And Dr. Alexander Francis

and myself have met with more than one case in

which typical asthma was similarly caused.

It would be matter of surprise, therefore, to find

that eye-strain has no setiological bearing on

alcoholism. A priori it is certain to be a factor : a

posteriori, however, it cannot be regarded as a

frequent factor : still less can it be claimed that the

use of spectacles has often resulted in recovery from

alcoholism. However, in a small minority this happy

result has been attained.

Of twenty cases examined under complete

* ' Migraine and Sick Headache.'

t 'Medical Gynaecology,' 1908, London, Sydney Appleton.

X' Gynaecology and Obstetrics in Relation to Ophthalmology,'

1908.

§ ' Lancet,' December nth, 1909, p. 1743.

g2 ON ALCOHOLISM

myoplegia, in fourteen were found errors of refraction

sufficient to cause eye-strain, and presumably, there-

fore, to lead directly or indirectly to alcoholism.

Six of the fourteen have done well, that is, remained

abstainers when last heard of from their medical

attendants. But in only two of these was the

evidence conclusive that the elimination of eye-strain

was the essential factor in the patient's convalescence.

In the other four the glasses prescribed may or

may not have been the chief factor : probably in

all they were contributory ; and it is obvious that in

none could they have been other than advantageous

generally. The two cases seem worth describing in

detail.

Case of Agoraphobia, etc., and consequent Alcoholism due

to Eye-strain.

A clergyman, aged 45 years, had suffered for twelve years

or more from a painful sensation of constriction round the

head, associated with paroxysms of vertigo and fright. Theconstrictive sensation was rarely absent while he was awake :

the vertigo and fear attacked him whenever he attempted

to cross an open space. In order to pass from the vicarage

to the church it was necessary to cross the marketplace.

He was unable to accomplish this without assistance or

without alcohol. At first a small dose of alcohol dispersed

the agoraphobia and relieved the sense of constriction, but

as time passed the effectual dose increased. He took

alcohol in steadily increasing doses in order to continue his

work. He had in consequence several " nervous break-

downs." He had many holidays and several sea voyages,

and went through more than one rest-cure, all with

temporary benefit. But his symptoms returned on resuming

his work. A week before his admission he had had an

EYE-STRAIN 53

attack of delirium tremens, previous to which he had been

drinking about a bottle of whiskey a day.

His eyes were then examined by an oculist, who reported

as follows :" Under atropine he has 3 D. of hypermetropia

with extra o"5 D. of astigmatism in each eye (oblique axes).

I have ordered him a little under the full correction to begin

with, to be worn in spectacles for all purposes, and

constantly. Before he had a mydriatic he could see f with-

out correction, owing to the exertion of accommodation,

but + 2"5 D. spherical gave the best part of f. At his

age there is not much more than 3^50 to 4 D. of accommo-

dation, so that he has been using a large proportion of his

total for distant vision for some considerable time, and it

is fatiguing to use more than two-thirds habitually."

Correction of the above errors by glasses removed his

symptoms at once. The sensation of constriction from

which he had suffered continually for many years left him

almost immediately, and he experienced no difficulty in

crossing open spaces. Nine months later he had had no

return of either symptom, and remained an abstainer.

Case of Frontal Neuralgia and consequent Alcoholism due

to Eye-strain.

A lady, aged 41 years, had suffered since puberty from

bilateral frontal neuralgia, the pain shooting down the

cervical spine and into the triangles of the neck, where the

glands seemed to become enlarged and tender : it extended

sometimes to the mid-sternum. Her worst attacks were

just before and just after each menstrual period, but they

were liable to occur at any time. Alcohol always gave

relief, and she ascribes her inebriety very largely to her

neuralgia. Under examination there was found to be i'S D.

of hypermetropia in one eye and 125 D. in the other; in

addition there was 1 D. of astigmatism in both. After

correction by glasses the neuralgia practically disappeared.

54 ON ALCOHOLISM

Two years later she remained well as regards alcoholism,

and very much better as regards neuralgia.

It is noteworthy that in both the above cases the

symptoms were greatly relieved by the atropine

myoplegia which preceded the examination.

There is a certain degree of similarity amongst

patients whose alcoholism depends primarily on eye-

strain—a similarity which, however, they share with

many others. As was to be expected, their occupa-

tion is usually such as demands continued use of the

eyes at close range : whether astigmatic or not, they

are usually hypermetropic : they nearly all claim to

be endowed with excellent sight : they have begun

the use of alcohol, not as a self-indulgence, but as a

drug for the relief of special symptoms, or to stimu-

late flagging energies and increase their output of

work. They drink as a rule in secret ; and they do

not for long periods become intoxicated, at any rate,

overtly so. In short, their histories resemble histories

of drug cases rather than ordinary cases of alcoholism.

Morphinism.—In certain communities, especially

the oriental tropics, where the action of opiates is

very generally known, alcoholism leads not infre-

quently to morphinism : usually morphine is taken in

the first place for its sobering influence in emergen-

cies. But the converse is not true. Morphinism is

not a common exciting factor of alcoholism,* although

* It would appear from quite recent experience that in districts

where opium is systematically used by the population there is a decided

danger of alcoholism following on any shortage in the supply of the

drug. The last Government Report on Wei-hai-wei states that the

diminution in the use of opium (brought about by recent legislation)

seems to be leading to excessive use of alcohol. Though drunken-

ness cannot yet be said to be prevalent, cases are undoubtedly morenumerous.

MORPHINISM AND ALCOHOLISM 55

a certain number of morphinists resort eventually to

alcohol in order to avert the danger of further in-

creasing the dose of the drug when tolerance to

morphine has become well established. Nevertheless,

some (morphinists, opium eaters, laudanum drinkers

and others) become alcoholists subsequently to con-

valescence from the original drug habits. And the

form of alcoholism then set up is, in my experience,

very severe. Perhaps it is worse when alcohol has

been used in order to break the drug habit, as in the

following case :

Severe Alcoholism, replacing Laudanum Drinking.

A native of Hindustan contracted the habit of drinking

laudanum for asthma, eventually taking several fluid ounces

a day. Hitherto an abstainer from alcohol he determined

to break himself of his opium habit by substituting whiskey.

Herein he succeeded, but found that the whiskey required for

his purpose varied between two and a half and four bottles

per diem. He failed to reduce this amount, and entered

thesanatorium some months later to be treated for alcoholism.

This is, of course, an extreme case.

But the danger of falling into severe alcoholism

continues for a considerable time—many months at

any rate—after the patient has been successfully

weaned from morphinism. It is well recognised that

the danger of relapse into morphinism is acute just

after complete withdrawal, and only subsides slowly :

this is owing to the periods of depression and conse-

quent craving for the drug, which continue to recur,

but at lengthening intervals, and with decreasing

severity. And if, during this somewhat indefinite

period, alcohol is taken as a lesser of two evils, it

56 ON ALCOHOLISM

commonly happens that the patient becomes a

Solent and impulsive drinker, although he maynever before have had any tendency to alcoholic

excess. Several examples have occurred. The follow-

ing is one in which recovery had not taken place six

months ago

:

Case of alternating Cocoainis?n, Morphinism, and

Alcoholism.

A gentleman, aged 25 years, had at the age of eighteen

used cocaine, obtained from a chemist for toothache. Hecontinued to paint his gums with the solution of the drug

when he had ceased to have toothache : this for about six

years. He was then advised by a medical man, himself a

drug habitue, to use morphine hypodermically, in order to

free himself from the cocaine habit. In this endeavour he

was successful, but found it impossible to refrain from using

morphine. Within twelve months he was taking about twelve

grains a day. On several occasions he had been " cured "

of the habit in different institutions, twice in this sanatorium,

but he always relapsed within a few weeks. On the last

occasion he took to alcohol instead, and quickly became avery impulsive drunkard. Several times since he has alter-

nated between alcoholism and morphinism, and exhibits

alternately many of the features peculiar to each form of

narcomania. When indulging in morphine, he is an anaemicand debilitated neurotic, timid and diffident, careful in his

dress and fastidious in his habits and language : whendrinking, he becomes florid and bloated, overbearing andquarrelsome, careless in his dress, dirty in his habits andmuch given to profanity. It is true to say that he has twopersonalities—a morphine and an alcoholic personality.

Whichever of the two habits is the worse for himself, thereis no doubt that the alcoholism is the worse for his relatives

and friends, who, when I last heard of the patient, werecongratulating themselves on his reversion to morphine.

gout 57

Bearing in mind all such cases, it cannot too

strongly be insisted that the use of alcohol is fraught

with exceptional danger, both in the process of with-

drawal of morphine (and no doubt other narcotic

drugs) and for a considerable time afterwards.

Gout.—There is no doubt, of course, that gout is

often a result of alcoholism, at any rate, of some forms

of alcoholism. But some authors regard it also as a

cause. The variety chiefly blamed is irregular or

abarticular gout (Crothers). But abarticular gout

may mean almost any kind of functional disorder

:

by some, many asthmas and various types of head-

ache are included under the head of gouty affections.

And if this classification is admitted, then undoubtedly

gout must often be blamed for alcoholism. But there

is a clearer and more direct relationship between the

two, one example of which was seen in the sana-

torium. The patient was a quite moderate drinker

of beer, which he took only at meals. Suddenly he

had an acute and typical attack of articular gout,

which laid him up for two or three weeks. He was

ordered never to take malt liquors of any kind again,

but to limit himself to whiskey and soda. The change,

however, was the beginning of inebriety. Before a

year had elapsed, he had advanced so far in alcoholism

that he was obliged to enter the sanatorium for

treatment.

Extreme physical fitness.—It must be admitted that

inebriety of whatever form has no necessary connec-

tion with bad or indifferent health,orwith pathological

affections of any kind. Many patients maintain

that so long as there is anything at all the matter

with them, they are safe ; and that the danger of an

58 ON ALCOHOLISM

outbreak commences only when their physical health

has returned to a high level—when they are feeling

particularly " fit." But it does not follow that in all

such cases the sensation of fitness is the cause of the

succeeding outbreak. It may be a mere premonitory

or initial symptom of a recurring outbreak of dipso-

mania. It is to be remembered that the same feeling

of extra well-being has been observed not infrequently

regularly to precede attacks of migraine, asthma, and

even acute articular gout.

CHAPTER III

Clinical classification of alcoholism; recurrent or intermittent; chronic

or continuous—Dipsomania—Pseudo-dipsomania—Chronic or

continuous alcoholism, inebriate and sober— Intermediate cases;

absence of sharp lines of demarcation between the four varieties

of alcoholism; consequent difficulty of classification—Dipso-

maniac craving and alcoholic craving.

The zetiological classification outlined in Chapter I

does not accurately harmonise with, or even include,

all the clinical varieties of alcoholism. Similarity of

known causation does not involve similarity of

results : which means simply that our knowledge of

the factors of alcoholism is at present far from

complete. Obviously, an identity of causation must

necessarily be followed by identity of residts.

Many clinical classifications have been suggested,

each having some special advantage. The classifi-

cation here adopted has perhaps the advantage of

simplicity ; but like all others it must be regarded

provisional.

Primarily, alcoholism may be divided into : (i) re-

current or intermittent; and (2) chronicorcontinuous.

The former is often spoken of loosely as dipsomania,

the latter, equally loosely as chronic inebriety. Such

a rough classification involves at least two fallacies :

(a) the majority of intermittent alcoholists are not

II. Chronic or con-

tinuous alcoholism.

60 ON ALCOHOLISM

dipsomaniacs ; and (6) a very large proportion of

chronic alcoholists are not inebriates at all.

These fallacies may be avoided by sub-dividing

each class into two, as follows :

11.Dipsomania or true

dipsomania.

2. Pseudo-dipsomania.

3. Chronic inebriate

alcoholism or

chronic inebriety.

4. Chronic non-ine-

briate, or sober,

alcoholism.

The above four classes could be further sub-

divided, but little would be gained by this : even as

they stand, the dividing lines between them will be

found to be sufficiently indefinite.

Dipsomania.

Dipsomania, or true dipsomania as it is often

termed, has important distinctions from pseudo-

dipsomania. By many writers it has been removed

altogether from the general category of inebriety,

and classed as intermittent insanity—a recurrent

mono-mania. Whether such is strictly correct or

not I am unprepared to say ; nor do I think the

question can be definitely settled at present. It is

certain, at least, that the cases referred to are not

often found in asylums for the insane.

In dipsomania there is complete indifference to

—

sometimes even distinct aversion from—alcohol of

all kinds during the quiescent interval. The interval

TRUE DIPSOMANIA 6l

between the onsets of any two paroxysms may be of

quite regular duration—some writers state that this

is so in the majority of cases. But in my own expe-

rience exact regularity of intervals has been excep-

tional. At the end of the interval "there is noticed

an alteration in character and temper that forewarns

those who have anything to do with the patient "*

that an attack is impending.

All the points in this description are important.

The indifference to alcohol during the interval is com-

plete : the alteration in character and temper precedes

the consumption of even a small quantity of alcohol;

and the change is without apparent cause. The periodi-

city of the disorder is seemingly inherent. Thefollowing two cases are the most typical examples

of true dipsomania which have been brought to the

sanatorium :

Case i.

—

True Periodic Dipsomania.

A tradesman, aged 50 years, entered during a paroxysm.

Since the age of fifteen he had suffered from periodic out-

breaks of dipsomania, which had steadily increased in

severity, but not, fortunately for him, in frequency. Theparoxysms were widely separated, the intervals varying

between eight months and four years : usually they lasted

two or three years. There was never any apparent cause

for the attack, but the patient could always recognise its

approach by indefinite but well-known symptoms, which

began four or five days before he touched alcohol. During

this premonitory stage he would carry on a fight of steadily

increasing severity against the craving for alcohol : by a

very special effort of will he could hold out for six days,

* ' Disease of Inebriety.' By the American Association for the

Study and Cure of Inebriety, 1893, p. 29.

62 ON ALCOHOLISM

never more. The paroxysm would last two, three or more

weeks—in fact, until he was completely prostrated by gastric

catarrh, incessant vomiting, etc., and confined to bed in the

hands of his medical attendant.

Many points in this case are of extreme interest. During

his long quiescent intervals he rarely touched alcohol in

any form, for the simple reason that it had no attraction for

him. He was then a hard-working and successful trades-

man, much liked and highly respected in his community.

But on rare occasions he would be at some convivial

meeting—for example, a masonic banquet where he occu-

pied an official position. Then he would take a few glasses

of whiskey " out of consideration for the feelings of the

company," or more probably to avoid drawing attention to

his known weakness. On such occasions (i) a very small

quantity of spirits would get into his head—he would showsymptoms of slight intoxication ; but (2) there would never

be the least temptation to continue drinking on the following

day. On the other hand, at the commencement of one of

his regular forewarned outbreaks (1) he would take very

large quantities of spirits without showing any of the signs

of even slight intoxication, and (2) the impulse to continue

drinking on the following day would always be irresistible.

The second case shows a remarkably regular

periodicity : it demonstrates also the ease with

which the dipsomaniac paroxysm may be aborted,

even when it has clearly commenced, but especially

on the rare occasions when the patient can be brought

under medical supervision during the premonitory

stage, that is, before any alcohol has been indulged

in. The treatment adopted is, in my view, the best

known method of dealing with dipsomania. Un-fortunately, for obvious reasons, the opportunity

for such treatment is rarely afforded.

PERIODIC DIPSOMANIA 63

Case 2.— True Periodic Dipsomania.

A gentleman, aged 39 years, business manager of a large

daily paper, entered the sanatorium in May, 1908, very

drunk and necessitating special attendants. He had been

drinking hard for three weeks. The history which he gave

later showed that he was a true periodic dipsomaniac, the

attacks coming on exactly every three months (ninety to

ninety-one days). This had been the case for twelve years,

before which he had been a moderate but regular drinker.

In the intervals between his paroxysms he was an abstainer,

and there was a distinct premonitory period lasting six or

seven days before he commenced to take alcohol. Thepremonitory symptoms were always the same, and were

manifest to others. They were restlessness, inability to

concentrate his attention, irritability of temper, insomnia,

and continuous and unquenchable thirst ; but during the

whole of this stage there was absolutely no desire for

alcohol. All his symptoms would increase up to the point

at which craving for alcohol commenced : this would usually

be on the sixth day. The period of drinking which ensued

would, if not interfered with medically, last from three to

four weeks, in fact until the patient was prostrated with

constant vomiting. On a few occasions he had success-

fully resisted the attack : then his symptoms, which were

those of the premonitory stage plus craving for alcohol,

would last just a fortnight. Thus he had occasionally been

an abstainer for six months continuously.

He was treated with apomorphine as described in the

chapter on treatment.

He remained well for six months, and re-entered the

sanatorium in November, 1908. On this occasion he had

been taking alcohol for six days only.

He next re-entered in February, 1909, in the same state

of intoxication, but having been taking alcohol for only

three days.

64 ON ALCOHOLISM

His last admission was in the following April. On this

occasion he had not commenced the alcoholic stage. Hewas in the fifth day of his premonitory period, and was

drinking water continuously.

The case well illustrates the value of apomorphine in

dipsomania. When intoxicated on admission, he was given

a full emetic dose of this drug (say TV gr.) followed by a

few small doses during the next day or so. On his last

admission he merely had ^ gr. and -4V gr. respectively

at bedtime on the first two days. Before entering he had

had very little sleep, and that broken up into " snatches."

After the first dose of apomorphine he slept for seven

hours continuously, and expressed himself as very muchbetter next day, though still somewhat thirsty. After the

second dose he slept for eight hours continuously, and

expressed himself as absolutely well next day. All his

symptoms had then ceased : in fact the paroxysm had been

aborted.

It was explained to him that in order to break up the

pathological tendency to recurrence, it was probably almost

as necessary to cut short the premonitory period as the

alcoholic stage. Accordingly he promised to come in next

time at the very commencement of the warning symptoms.

It is to be regretted that herein he failed.

Such cases of true dipsomania in which the

periodicity is undoubtedly inherent and. has no

relation to external circumstances are, I am inclined

to think, much rarer than is commonly supposed

:

only twenty-one have been admitted during the last

six years. In them there would seem to be a double

personality—an interim and a paroxysmal per-

sonality : this is shown by a change not merely in

character and temper, but in certain physical con-

ditions. The psychical change does not dependupon alcohol, for it always occurs before any alcohol

NON-ALCOHOLIC DIPSOMANIA 65

has been consumed. The premonitory stage maylast many days, even a week, before alcohol of anykind is indulged in. During the paroxysm there

may be (as in Case I detailed above) a tolerance of

alcohol which is greatly in excess of that in the

interval ; and enormous quantities of spirits may be

consumed without marked signs of intoxication.

During the interval the patient is usually anabstainer; but in some cases he takes alcohol in

moderation. At this time he has no special

tolerance of alcohol and moderate amounts mayshow. At the same time he has, in most cases, nospecial tendency to exceed : indeed, it would be

incorrect to regard him at that time as in any sense

an inebriate or even an alcoholist : he is, in fact, a

normal individual.

The view that alcohol is not a direct factor in

cases of dipsomania is strengthened by the fact that

paroxysms of " non-alcoholic dipsomania " maycontinue to recur in special circumstances. Thefollowing is an example :

Recurring Non-alcoholic Dipsomania.

A gentleman, aged 50 years, had suffered for many years

from dipsomaniac outbreaks, recurring at intervals of three

months. He suffered also from mitral insufficiency.

Steadily increasing breathlessness on the least exertion at

length confined him to his room. There was no alcohol in

his immediate vicinity, nor was he physically able to procure

any. Yet his periodic attacks of dipsomania continued to

recur at their long accustomed intervals. He would lose his

appetite and become sleepless, " his brain working continu-

ously " in spite of all his efforts to prevent it. He would beintensely irritable, and tormented with an increasing desire

5

66 ON ALCOHOLISM

for alcohol in quantity. He always insisted, however, that

the craving from which he suffered then was trifling com-

pared with the craving from which he would suffer should

he take a single glass of spirits. These symptoms would

persist for just one week, as they did when he indulged in

alcohol. They would then subside somewhat suddenly. At

their subsidence there would be a heavy discharge of urates,

followed by diuresis.

The onset of a distinct craving for alcohol preceding

the imbibition of even a small quantity of it has been

accepted in the sanatorium as the main symptomwhich distinguishes dipsomania from pseudo-dip-

somania. The distinction may not be altogether

scientific, but there are cogent reasons rendering its

adoption expedient : these chiefly concern prognosis

and treatment, and will be considered later (p. 240).

While the presence of a distinct premonitory stage

is, unless otherwise accounted for, pathognomonic

of dipsomania, the absence of such a stage cannot be

taken to exclude this affection ; for there are cases

in which premonitions of all kinds are wanting.

The patient, who may have been a total abstainer for

many months, and who may be at the time in

perfect physical and mental health, is suddenly

seized with the craving and promptly succumbs.

Usually a paroxysm of heavy drinking supervenes at

once : less often the first indulgence gives temporary

relief, and the climax is worked up to gradually.

Case of Dipsomania without Premonitory Stage.

An unmarried lawyer, aged 29 years, with marked paternal

heredity to alcoholism, had commenced drinking to

excess at the age of seventeen. Since he was nineteen he

MENSTRUAL DIPSOMANIA 67

had suffered from recurring outbursts of inebriety, separated

by intervals of total abstinence. The intervals, which were

never of equal duration, had of late been getting shorter.

He never had the least warning of the outbreak. Quite

suddenly he would be seized with the idea that he must

have alcohol, rush into the nearest hotel and drink. Atfirst he would take one glass only on the first day : not

more than two or three on the second ; and only on the

third abandon himself to heavy and continuous drinking.

But of late his heavy drinking had always begun on the

first day. The paroxysms yielded only when gastric

catarrh and vomiting rendered further drinking impossible.

During his bouts he was always intensely miserable and

dangerously depressed : he had made several serious though

unsuccessful attempts to take his own life at these times.

Such cases are uncommon ; and fortunately so,

since they seem to be peculiarly resistant to treat-

ment. It is a question, however, whether the

absence of premonition in some of them is real. Thepatient often lays special stress on the excellence of

his health at the time of the onset of the craving

;

and this feeling of ultra well-being may in itself

constitute a premonition. One patient assured methat so long as there was anything the matter with

him he always felt safe ; that his attacks never began

except when he was feeling particularly fit. Wemay here appropriately recall the fact that asensation of ultra well-being has long been a recog-

nised forewarning of an impending attack in manyparoxysmal affections.

Outbreaks of inebriety preceding, or coinciding

with, the menstrual periods, constitute a classification

difficulty. It is doubtful whether they should be

classed as true dipsomania. In the sanatorium a

68 ON ALCOHOLISM

few of them have been so classed, but only when

there have been present features typical of dipso-

mania other than menstrual periodicity. Menstrual

dipsomania should perhaps be allotted a place by

itself. It differs from dipsomania proper in several

respects ; and it is certainly far more amenable to

treatment, and consequently justifies a better prog-

nosis. The special tendency for outbreaks of

inebriety to occur at, or about, each menstrual epoch

renders somewhat indefinite the line of demarcation

between dipsomania and pseudo-dipsomania.

It remains to consider an attribute of dipsomania

which is almost constant, entirely inexplicable (except

on the view that the disorder is a form of insanity),

and from the standpoint of treatment and prognosis,

altogether deplorable. I refer to the compelling

tendency to secretiveness which, in the vast majority

of cases, seizes on the sufferer at the very approach

of every attack. Patients who are normally candour

itself, become, at the commencement of the premoni-

tory stage, obsessed with the impulse to conceal the

imminence of a paroxysm from everyone—relatives,

friends, and medical advisers. The tendency to

secretiveness is not limited to dipsomania ; it is

present more or less in all forms of inebriety. Butin all other forms it is in some degree intelligible.

In none but dipsomania is there a clear premonitory

stage ; therefore a patient suffering from the moreordinary forms of alcoholism has always actually

commenced drinking when he realises that he is in

for a relapse. And it is easy to understand, if not

to excuse, the motives which urge to concealmentof one who has broken his word. But who can

DIPSOMANIAC SECRETIVENESS 69

explain the mental attitude of the patient who has

long suffered from regularly recurring outbreaks of

dipsomania : whose every outbreak is preceded by a

week's clear warning : who knows that at any time

during this premonitory week it is a simple matter

to avert the impending outbreak : who is undoubtedly

anxious, at all other times, for recovery ; and yet

immediately he becomes aware that an attack is

impending, and throughout the whole of his pre-

monitory period, habitually goes to absurd lengths

to prevent the least suspicion of his dangerous condi-

tion from leaking out ? Nevertheless, this attitude

is certainly the rule rather than the exception. Wecan only conclude that the uncontrollable impulse to

secretiveness is an essential part of the paroxysm.

The secretiveness of the patient is peculiarly un-

fortunate, since it constitutes a very effectual, though,

I believe, the sole, bar to successful treatment in

these cases. In the few cases in which the secretive-

ness of the patient is out-manceuvred, and the patient

brought under treatment before the drinking stage is

reached, the results are excellent.

The term " dipsomania " has been used in manydifferent senses by different writers. Some have

applied it to paroxysmal heavy drinking in which

the patient becomes distinctly maniacal and dan-

gerous to others—if not actively homicidal—in fact,

to acute recurrent mania brought on by gross alcoholic

indulgence. And it may be admitted that maniacal

drunkenness is relatively more common in dipsomania

than in other kinds of inebriety. But it is not

distinctive. Cases also occur which may be classed

as dipsomania according to the definition used in the

70 ON ALCOHOLISM

sanatorium, but in which the degree of intoxication

reached during the paroxysms is quite mild, and

certainly harmless to all but the patient himself.

Such a case is the following

:

Case of True, but Mild Dipsomania.

An independent gentleman, aged 58 years, had never been

an abstainer until he realised that at certain periods he lost

control of himself and was an inebriate. He then under-

went a four weeks' " cure " in America. This was succeeded

by a period of total abstinence lasting over twelve months.

Since then he has suffered from attacks of inebriety lasting

two or three weeks, and coming on, irrespective of circum-

stances, at intervals of six or seven months. Each attack is

preceded by a premonitory period lasting about a week :

his symptoms during this week seem to be indescribable,

but they are easily recognisable ; nor has he ever mistaken

them for anything else. During his attack he drinks sherry

only. He takes it at regular intervals throughout the day,

and once or twice if awake during the night—perhaps a

bottle and a half in twenty-four hours. He never becomes

more than very mildly muddled. The attack ceases

gradually in two or three weeks, without serious illness, such

as gastritis, prostration, etc. He remained five weeks in the

sanatorium. Twelve months later he had had no further

attack.

In another variety of dipsomania there is a long

premonitory period, the attacks themselves are pro-

longed, and they are apt to be separated by long

intervals. Such a case is the following:

Case of Dipsomania arising out of, and difficult to distinguish

from, Chronic Inebriety.

An unmarried brewer, aged 38 years, had been an

abstainer up to eighteen, a moderate drinker thenceforward

PSEUDO-DIPSOMANIA 71

up to twenty-four, and an occasional heavy drinker during

the next two years. From the age of twenty-six to that of

thirty-two he drank heavily and continuously. Then, getting

frightened, he became an abstainer for twelve months.

Afterwards he relapsed many times, his relapses being

separated by intervals of total abstinence varying greatly in

length. Clearly at this period of his history his case must

be classed as dipsomania, since each relapse into inebriety

was heralded by a premonitory period during which the

craving for alcohol was unmistakeable and progressively

increasing up to the point of breakdown. It seemed to him

that there was no escape from heavy drinking when once

the craving commenced : the longer he abstained, the more

insistent became the desire. Often his premonitory periods

had lasted several weeks. He remained in the sanatorium

for five weeks, and on leaving sailed direct for New Zealand,

when he started life afresh. Two years later he had not

relapsed.

Such cases graduate into, and would be classed by

many as, chronic inebriety. In the sanatorium they

are distinguished from chronic inebriety by the fact

that at each relapse the craving for, invariably

preceded the consumption of, alcohol.

Pseudo-dipsomania.

Far commoner and even more varied in character,

than dipsomania is the variety termed "pseudo-

dipsomania." By many medical men not specially

experienced in the subject of alcoholism the two

varieties are regarded as one. Indeed, any case of

intermittent inebriety, provided the outbursts are

sufficiently severe, is looked upon by them as one of

dipsomania; and it is easy to excuse this view.

Superficially, at any rate, pseudo-dipsomania may

72 ON ALCOHOLISM

closely resemble—may sometimes, indeed, be indis-

tinguishable from—dipsomania. The affection is

recurrent : now and then it may be periodic. During

the intervals, in both cases, total abstinence is the

rule; and in both the paroxysms may be equally

severe.

But looking a little deeper, important differences

are found. The recurrency or periodicity of pseudo-

dipsomania is never in any sense inherent—can

never be looked upon as part of the disease : it is

always dependent on external circumstances. There

is never any premonitory period. And, although a

premonitory period is occasionally wanting in dipso-

mania also, yet in dipsomania the first drink is

always preceded, if only for a few minutes, by a

distinct craving for alcohol : this antecedence of the

craving is the chief distinguishing feature of dipso-

mania. Now in pseudo-dipsomania there is never

any antecedent craving for alcohol : the craving

always succeeds and depends upon the taking of alcohol.

What, then, are the motives which lead to the taking

of the first drink in outbreaks of pseudo-dipsomania ?

One can only answer that they are innumerable, for

they depend upon the innumerability of circum-

stances. Moreover, they are substantially the sameas those which conduce to relapse after a period of

abstinence in ail kinds of alcoholism except pure

dipsomania. But whatever the motive, the drink

craving which follows consumption pursues the

same course, leads to the same results, and termi-

nates under the same conditions in pseudo-dipso-

mania as does the drink craving which precedes

consumption in a paroxysm of dipsomania.

EXPLANATIONS OF RELAPSE 73

The explanations or excuses advanced for thetaking of the first drink after a period of abstinenceare for the most part absurdly inadequate. And this

applies to chronic alcoholism, inebriate and sober,

not less than to pseudo-dipsomania. Withoutexception the patient will state that he had nocraving at the time, nor even any special desire. Hemay have been mixing with a drinking set, and havewearied of his companions' interminable chaff at his

teetotalism. " One glass can't hurt you " is the

phrase in constant use on such occasions ; andpresently the patient persuades himself that hebelieves it. Or, having remained free from both

alcohol and the craving for alcohol for many monthsafter leaving the sanatorium, he may come to believe

that he is " really cured" and can take a little withsafety, "just like anyone else." Again, he may think

that the time has arrived for testing himself: hewants to know whether it is true, as was so often

impressed upon him in the sanatorium, that a single

alcoholic drink will re-create all his old insatiable

craving. And the knowledge comes to him rapidly.

Hence it happens that there is a steadily lengthening

list of old patients who, having relapsed after a first

course of treatment in the sanatorium, have remainedwell for long periods after a second. The explana-

tion is simple. Though insistently warned that a

single drink would re-start the craving for alcohol,

and though courteous enough to agree, they did so

with a reservation. They did not really believe in

the " theory of the single drink ": probably they put

the medical superintendent down as an extremist,

though in the case of the Norwood Sanatorium this

74 ON ALCOHOLISM

official has consistently endeavoured to avoid any such

reputation. Be that as it may, however, it is found

that experience frequently succeeds where precept

has failed ; and on leaving the sanatorium for the

second time a considerable number of patients need

no further evidence.

It is commonly believed that those patients whoremain continuously abstainers after leaving the

sanatorium do so through the exercise of determi-

nation and will-power. This may be largely true,

but it is by no means exclusively true. If, as just

pointed out, the first glass which determines the

relapse is not taken in response to any craving for

alcohol, it follows that will-power is not essential to

refrain from it. The essential quality seems to meto be rather a power of intelligent imagination ; and

this view is confirmed on a re-consideration of the

characters of those patients who have proved the

most successful. Indeed, I have often wondered

whether we might not safely make the following

generalisation : Will-power is either unnecessary or

inadequate ; it is unnecessary for the avoidance of the

first glass, it is practically always inadequate for the

avoidance of the second.

Many other explanations are offered of the first

drink which is the determining cause of the relapse.

The patient contracted a cold or a slight chill—he

may merely have got his feet wet—and he success-

fully cheated himself into the belief that a glass of

hot spirits and water was necessary to prevent an

attack of pneumonia or other severe illness. Finally,

the initial drink which re-started the craving mayhave been really accidental in so far as the patient

RELAPSE THROUGH ACCIDENT 75

himself was concerned. A lady had left the sana-

torium and remained quite well for some months.

But the motor-car in which she was travelling with

her husband was upset, and she was thrown out,

fracturing her left humerus. She fainted, and a

bystander poured some brandy down her throat.

Immediately the craving for alcohol returned, andshe was obliged to return to the sanatorium as soon

as she was well enough to travel. A very corpulent

male ex-patient fainted from the excessive heat which

afflicted this country in July, 1911. He was watching

a cricket match at the time, and an acquaintance,

ignorant of his failing, administered brandy while he

was semi-conscious. Relapse into heavy spirit-

drinking followed in the evening. " Wincarnis " has

accounted for several relapses. Three or four old

patients have relapsed through drinking cider, which

for some unexplained reason seems to be widely

regarded as a non-alcoholic beverage. And twohave relapsed as the result of a practical joke at the

hands of a " friend." They had called for sometemperance drink such as ginger-ale, and the friend

had surreptitiously added some spirits. One of these

patients entirely failed to see the joke : indeed, so

lacking was he in any sense of humour at the time

that he administered a somewhat severe thrashing to

the joker.

From all standpoints it is a particularly regrettable

fact—and one which more than all else seems to

demonstrate that the important factor in relapse is

the actual consumption of alcohol rather than the

circumstances in which it is consumed—that the

sacramental wine itself has been the instrument of

j6 ON ALCOHOLISM

relapse : this has happened in the case of more than

one clergyman admitted to the sanatorium. Theamount of wine which the priest officiating at the

Communion Service is called upon to consume mayin occasional circumstances amount to more than

very little. In one of the concluding rubrics at the

end of the Communion Service of the Church of

England, it is directed that if at the end of the

Service any remain of the consecrated bread and wine,

" it shall not be carried out of the Church, but the

priest and such other of the communicants as he shall

call unto him, shall, immediately after the Blessing,

reverently eat and drink the same." I am given to

understand that in most churches the custom of

calling up some of the communicants to assist in the

consumption has fallen into such desuetude that a

revival of it by any individual clergyman would

certainly provoke comment. Hence it may happen

that the priest is left alone to fulfil this duty.

Essential periodicity has been accepted as pathogno-

monic of (true) dipsomania (p. 66). But periodicity

(not always exactly regular) may characterise some

cases of pseudo-dipsomania. Omitting from con-

sideration the periodic influence of the menstrual

function, periodicity in pseudo-dipsomania is always

dependent on periodicity of circumstances. There

may be regularly (or irregularly) recurring sources of

depression, worry, boredom, or stress. One patient

enters the sanatorium after every attack of influenza

to which he is very subject. Another is prone to

relapse about quarter day : another at the approach

of his half-yearly balance : yet another, whenevervisited by a peculiarly tactless female relative. A

PERIODICITY IN PSEUDO-DIPSOMANIA 77

childless woman drank heavily for many years at

regular intervals of a few weeks, remaining an

abstainer between times. The attacks of inebriety

were determined simply by the periodic absences of

her husband, a commercial traveller, to whom she

was much attached. Mere press of work has deter-

mined outbreaks : influenza and other epidemics

frequently determine relapses in the case of medical

men. Incidentally, however, it may be mentioned

that press of work may operate in the opposite way,

in which case relapse is prone to follow the removal

of the strain. The accessibility to alcohol may be

periodic : this is well illustrated in the case of the

white bushmen in Australia and other thinly

populated countries, who visit the townships only at

long intervals. Many pseudo-dipsomaniacs were

originally continuous drinkers, but owing to threat-

ened disease, loss of employment or social standing,

make courageous, but only intermittently successful,

efforts to become abstainers. They are successful

under fairly happy circumstances, but fail when

worried or bored. Thus they tend to develop a

certain periodicity, which is regular or irregular

according to circumstances.

The most curious example of regular periodicity in a

pseudo-dipsomaniac which came under my notice was in a

highly neurotic man who had outbreaks of inebriety lasting

two or three days, and separated by intervals of total absti-

nence lasting almost exactly twenty-eight days. The case

might in a sense have been labelled menstrual dipsomania;

but the psychical alteration which determined each outbreak

was in the patient's wife, who was herself a total abstainer.

Two days before the commencement of the menstrual flow

this lady's temper underwent a remarkable change for the

78 ON ALCOHOLISM

worse : normally even-tempered, she then became irritable

and cantankerous to such a degree that her husband, in his

own words, was " driven to drink in self-defence." Perhaps it

is fortunate for both parties that in this case the menopause

is unlikely to be much longer delayed.

As above stated, a distinct premonitory stage is

pathognomonic of (true) dipsomania. But even in

this connection mistakes may arise. There is a

type of inebriate who assiduously studies the whole

subject of inebriety, not limiting his reading to the

works of standard authorities. He embraces enthu-

siastically the view that inebriety is a disease, andis obviously anxious to shirk all individual responsi-

bility for his numerous failings. Should there be

any hereditary taint of inebriety in his family, nomatter how distant, he enlarges on it, and advances

it as an explanation or excuse for even future lapses.

These patients often earn the reputation of having a

regular premonitory stage heralding each outbreak of

inebriety. What really happens, however, is this:

They have more or less deliberately indulged in

alcohol. Indulgence does not in their case imme-

diately lead to an outbreak, but does so infallibly in

the course of, say, a week. During this week they

have been drinking secretly, and refuse to admit their

relapse until the effects have become obvious. Theyfind it convenient to encourage the idea of a pre-

monitory stage and of their own consequent irre-

sponsibility : thus they are called upon to endure less

expostulation, and enjoy far more sympathy. Suchpatients are not infrequently married to wealthy

wives ; or they may be dependent on relatives for

their present or future income.

TRUE AND FALSE DIPSOMANIA DIFFERENTIATED 79

Some (I think only a few) dipsomaniacs during

their quiescent intervals are able, as above pointed

out (p. 62), to take alcohol in strict moderation : they

are at the time normal individuals in all respects.

Such is never true of pseudo-dipsomaniacs. Thelatter are always the same in respect of alcohol : they

are always dependent on strict abstinence in order to

escape inebriety, and always, therefore, more or less

at the mercy of circumstances—circumstances which

lead to the taking of the first glass of stimulant. In

this one respect, at any rate, they are less fortunate

than the true dipsomaniac. On the other hand, they

have it within their power to avoid this fatal first

glass, the which cannot truly be said of mostdipsomaniacs.

Finally, the occasional greatly increased tolerance

of alcohol which may characterise the paroxysm of

dipsomania is never seen in pseudo-dipsomania : the

tolerance of alcohol exhibited by pseudo-dipsomaniacs

is constant, or if variable, dependent on the length

of time they have been drinking. Commonly, of

course, the time factor does not enter into this

question.

The essential distinctions between the two varieties

of recurrent or intermittent alcoholism may be

arranged in double column as under

:

Dipsomania. Pseudo-dipsomania.

Usually a distinct pre- Never any premonitory

monitory stage. stage.

Craving for alcohol al- Craving for alcohol never

ways precedes consumption. precedes, but always follows

and depends upon, con-

sumption.

8o ON ALCOHOLISM

Dipsomania.

Recurrence of paroxysm

without apparent cause.

May be regular periodi-

city, which is then inherent

—part of the disease.

Patient sometimes able to

take alcohol in moderation

during interval.

May be a greatly in-

creased tolerance of alcohol

during paroxysm.

Pseudo-dipsomania.

Recurrence of paroxysm

dependent on circum-

stances.

Occasional regular peri-

odicity, which is then always

due to regular periodicity

of circumstances.

Patient never able to take

alcohol in moderation, ex-

cept for a short time.

Never any variation in

the degree of tolerance of

alcohol.

Chronic or Continuous Alcoholism.

Chronic or continuous alcoholism, in typical cases,

differs so widely in its clinical manifestations from

both varieties of recurrent, or intermittent alcoholism,

as almost to constitute a separate disease. Chronic

alcoholists are really drug habitues, and are strictly

analogous to chronic morphinists. As in morphinism,

so in chronic alcoholism, always there is established

tolerance of the drug : that is to say, alcohol, except

in large and continually increasing doses, ceases to

exert its well-known physiological effects. This

establishment of tolerance is the salient feature which

distinguishes this form of alcoholism from the forms

already considered.

The histories of patients suffering from chronic

alcoholism are remarkably uniform. Almost always

they have been for a more or less prolonged period

moderate drinkers. Originally, in their school days

CHRONIC OR CONTINUOUS ALCOHOLISM 8l

perhaps, they took light ale with their meals : later,

wine with perhaps a liqueur to follow : a little later,

spirits in the form of a " night-cap " would be added

;

and later still an occasional " nip " between meals.

These nips between meals would steadily, but perhaps

only slowly, increase in number, and so also would the

night-caps. Should the drinking be done at home,

or in the houses of friends, the size, as well as the

number of nips, continually increase. And the same

is true of hotel and club life in countries like Australia,

where the practice holds to allow customers at the

bar, or in the smoke room, to help themselves. In

any case, the passage from moderate to immoderate

drinking is quite imperceptible: the chronic alcoholist

can never say, even approximately, when he first

began to exceed. Indeed, he frequently refuses to

admit that he has ever " exceeded " at the time he

first applies for medical advice, although he may then

be taking considerably over a bottle of spirits every

twenty-four hours. He defines excess as the amount

necessary to cause intoxication, and quite probably

he has never been intoxicated in his life—at any rate,

overtly intoxicated. He has, in fact, through frequent

small but ever-increasing doses of alcohol, eventually

succeeding in establishing a high grade of tolerance.

To this he is apt to refer with some pride, regarding

it in the light of a valuable acquirement, and as an

evidence of his powers of resistance. But herein he

ignores, though he is fully cognisant of, the fact that

his acquired capacity carries with it a more than

compensatory incapacity—the total incapacity to

remain even temporarily on his ordinary mental and

physical level in the absence of his daily or hourly

6

82 ON ALCOHOLISM

allowance of alcohol. His tolerance of alcohol mayindeed be regarded as in most cases an accurate measure

of his intolerance of its absence. In severe cases the

chronic alcoholist lives in continual terror of finding

himself so placed as to be unable to procure alcohol

in adequate amount, feeling assured that in those

circumstances he would be more than threatened with

some grave nervous complication. And many such

patients have to my knowledge been prevented for

years from entering a sanatorium, and even from

seeking medical advice, because they understood that

the invariable practice of the profession is to insist

upon sudden and complete abstinence from alcohol

in all cases. It is the wide-spread prevalence of this

belief that has done more than anything else to throw the

medical management of alcoholism and inebriety into the

hands of unqualified and often incompetent persons.

The chronic alcoholist, whether inebriate or not,

is distinguished by the frequency, ubiquity and

severity of his tissue changes. It is solely in the

chronic alcoholist that the infrequent complication,

cirrhosis of the liver, whether atrophic or hyper-

trophic, arises. Here also are found practically all

the cases of toxic neuritis, and most of those of toxic

albuminuria (a complication not hitherto sufficiently

recognised), not to mention acne rosacea and other

proverbial signs of alcoholism. And it is chronic

alcoholism which, in the great majority of cases, leads

indirectly to the two chief alcoholic emergencies,

namely, delirium tremens and alcoholic epilepsy.

Medically, no very sharp line of demarcation can

be drawn between the two varieties of chronic alco-

holism—between chronic inebriate alcoholism or

INEBRIATE AND SOBER ALCOHOLISM 83

chronic inebriety, and chronic non-inebriate or sober

alcoholism : in practice the one graduates impercep-

tibly into the other. Nevertheless, psychologically,

the two must be regarded as entirely distinct. As a

matter of fact, the line of demarcation between them,

broad and ill-defined as it is, coincides accurately

with the dividing line between drunkenness and

sobriety—between what may be termed legal, and

purely medical, alcoholism. In the abstract of the

Report of the Departmental Committee on the law

relating to inebriates and their detention—a report

which is concerned solely with legal alcoholism—the

seventh proposition states that " in some, satiety is

produced before intoxication occurs ; in others,

intoxication occurs before satiety is produced "

(P- 7)-

The occurrence of satiety before intoxication com-

pletely excludes all question of inebriety, but on the

other hand, it allows full room for numerous cases of

very severe alcoholism—cases which constitute a

large proportion of those admitted into, and treated

in, the sanatorium. All such cases are of course

entirely beyond the scope of the report of the Depart-

mental Committee. They constitute the fourth

class—the class of chronic non-inebriate or sober

alcoholists : they might perhaps be termed simply

chronic alcoholists. The great majority have never

been intoxicated in their lives ; or if occasionally they

have shown symptoms, it has been due to some

accidental circumstance. They would regard a mere

suggestion of inebriety as insulting. And herein I

confess they have my sympathy. For the avoidance

of drunkenness implies a relatively high grade of

84 ON ALCOHOLISM

self-respect. At the same time they are, it must be

freely admitted, complete slaves to alcohol for the

time being; and are peculiarly exposed to the

dangers implied in the establishment of tolerance.

Many of them, of course, are secret drinkers, which

it has become the fashion to regard as the most

hopeless of all. But here again I am inclined to

dissent from the general view. Secrecy in drinking

certainly implies some degree of self-respect, and

whatever its result, it is commonly dictated by

motives of consideration for others, whether relatives

or friends. Nor have I found that as a class secret

drinkers are necessarily less likely to recover and

remain well than those whose habit it is to indulge

openly : indeed, I am inclined to think that the

reverse is true.

The majority of sober alcoholists when first coming

under notice are still managing their affairs, business

or professional, with some success : in many cases

no suspicion as to their habits has got abroad : the

knowledge is limited to a few. They apply for advice

only because they are beginning to suffer from alco-

holic complications, either insomnia, loss of appetite,

or painful neuritic affections, or because they find

they are forced continually to increase their daily

allowance of alcohol.

In the chronic inebriate satiety occurs only after

intoxication has been produced. But the degree of

intoxication is not as a rule more than mild : it

rarely brings them into the hands of the police. It

is, however, quite enough to show, and is commonlydescribed by such words as "muddled," "fuddled,"

and " a little mixed." Of such it is often said that

INTERMEDIATE CASES 85

they have not been to bed sober for years ; or that

they are " never drunk and never sober." Usually

they are induced to seek medical advice through the

moral pressure brought to bear on them by relatives,

friends or employers.

Intermediate Cases; Absence of Sharp Lines

of Demarcation between the Four Varie-

ties of Alcoholism ; Consequent Difficulty

of Differentiation.

Attention has already been called to the difficulty

of distinguishing clinically between dipsomania and

pseudo-dipsomania. This is mainly owing to the

practical difficulties experienced -in recognising (i) a

true from a false premonitory stage ; (2) the exist-

ence of an antecedent craving for alcohol ; and (3)

the inherency or otherwise of periodicity. But it is

due also to the existence of intermediate cases. Thusa patient may be both a dipsomaniac and a pseudo-

dipsomaniac. Some of his paroxysms may be pre-

ceded by a definite premonitory stage, during which,

though an abstainer, he is tormented by a steadily

increasing craving for alcohol ; while others are

plainly due to the incidental consumption of alcohol.

Several such cases have been admitted to the

sanatorium.

Occasionally a patient may suffer from an isolated

attack of dipsomania. At least, on no other grounds

does it seem possible to explain the following

occurrence

:

An articled clerk, aged 26 years, had drunk hard at the

University, and become an ordinary pseudo-dipsomaniac.

86 ON ALCOHOLISM

He was treated at the sanatorium for six weeks successfully.

Four months after leaving he took a holiday and went to

the seaside, where he put up at a large hotel. There he

found himself a stranger : friends whom he expected to

meet were away. He became depressed. Presently he

found himself longing for alcohol in quantity : his craving,

he explained, was really for intoxication, not merely for

alcohol, and this although he had remained a complete

abstainer for four months. This mental condition continued

for about thirty-six hours. He did not give way, however,

but having wired the sanatorium, re-entered with all speed.

On admission he was immediately set right by a small dose

of apomorphine, followed by half an hour's sleep.

This happened eighteen months ago. Since then he has

had no similar attack, and has remained well in all respects.

Analogous difficulties are found in separating cases

of pseudo-dipsomania from cases of chronic inebriety.

A patient may be both a pseudo-dipsomaniac and a

chronic inebriate by turns, or he may have been for

long years a chronic inebriate, and later, through

making intermittently successful efforts to abstain,

have become a mild pseudo-dipsomaniac. Again, he

may have intervals, more or less prolonged, of total

abstinence, followed by prolonged periods—periods

lasting weeks or months—of chronic inebriety.

Obviously no sharp line can be drawn between these

two varieties : they shade into each other at manypoints. Only typical cases can be clearly separated.

Finally, the same is true, perhaps in even higher

degree, of the distinction between chronic inebriety

(chronic inebriate alcoholism) and chronic non-

inebriate or sober Alcoholism. There is no difficulty

whatever in dealing with typical cases : a man mayhave been more or less intoxicated every day of his

INTERMEDIATE CASES 87

life for many years, or, though drinking heavily

every day, may never have been once intoxicated. But

there are many who, though drinking heavily every

day, become intoxicated only on rare occasions. Andthe word " rare " is differently interpreted by different

individuals. Such occasional bouts of drunkenness

are sometimes explicable by accidental circumstances.

The capacity to keep sober, in spite of heavy drink-

ing, is conditional upon the degree of alcoholic

tolerance which has been set up. If there is any

sudden increase in the amount of alcohol consumed,

or what comes to the same thing, in the amountconsumed in a given time, intoxication is liable to

occur.

A patient who habitually took a bottle of whiskey a

day proposed to spend Sunday afternoon and evening with

friends who were abstainers. Knowing he would be un-

unable to obtain any more whiskey until late at night, he

doubled his morning dose. As a result, acting on a friend's

advice, he changed his plans and spent that Sunday afternoon

at home.

Some chronic alcoholists keep sober only through

the exertion of will-power—in them intoxication ante-

cedes satiety—or because circumstances compel them.

Such from time to time find themselves under con-

ditions in which sobriety is not of supreme importance,

or so at least it seems to them. Then they " let them-

selves go," and become inebriates for the time

being. And there are innumerable other explanations.

Finally, it is not to be forgotten that many occasional

bouts of drunkenness are quite deliberate in origin

—they do not, that is to say, come under the head of

88 ON ALCOHOLISM

inebriety at all—as at " send-offs," special nights at

certain clubs, etc.

A gentleman, aged 32 years, who has been admitted into

the sanatorium far more frequently than any other patient,

well illustrates the frequent impossibility of accurate classi-

fication and " pigeon-holing " of cases of alcoholism.

Originally a moderate drinker, he became for a short time a

chronic inebriate. He then determined to become a total

abstainer. Herein he was only temporarily successful. Heis now for the most part a pseudo-dipsomaniac, but suffers

occasionally from attacks which must certainly be regarded

as true dipsomania. Furthermore, there is no doubt that

some of his attacks of inebriety are deliberate. His specu-

lative business, in which he is extremely successful from a

financial point of view, is of such a nature that outbreaks of

inebriety and consequent disappearance from his office, are

not, fortunately, or unfortunately for him, necessarily fraught

with much loss. And he has confessed to me that very

often, on the satisfactory conclusion of a " deal," he has

looked through his appointment book in order to ascertain

whether or not he could afford the time for a "spree."

Sometimes he found he could do so : then he would appear

at the sanatorium as a patient in the course of a week or

ten days. Again, finding early important business arrange-

ments, he would remain without difficulty a total abstainer

until slacker times.

Finally, it seems necessary to point out that there

is no sharp line of demarcation between chronic sober

alcoholism and chronic moderate drinking : the twoshade by altogether imperceptible gradations into

each other. Indeed, as already stated, the latter is

an almost invariable antecedent of the former.

dipsomaniac and alcoholic craving 89

Dipsomaniac Craving and Alcoholic Craving.

Use will be made in the following pages of twoterms, namely, "dipsomaniac craving" and "alcoholic

craving." For it would appear that there are twokinds—not, I am inclined to think, merely two de-

grees—of craving for alcohol. What will be referred

to as the dipsomaniac craving obtains almost solely

in the intermittent forms of alcoholism, namely

dipsomania and pseudo-dipsomania. Perhaps its

most marked manifestation is in the former, especially

the regularly periodic variety. Here the craving

antecedes, and therefore cannot depend upon the

consumption of alcohol ; but the antecedent craving

never approaches in intensity the craving which

succeeds the drinking of the first few glasses of a

drinking bout. The dipsomaniac craving, however,

is present also in pseudo-dipsomania, though here it

only succeeds consumption. Nevertheless, in both

varieties of intermittent alcoholism, the craving

(dipsomaniac craving) differs greatly—I had almost

said essentially—from what is about to be described

as the alcoholic craving.

The alcoholic craving occurs in its most typical

form in chronic alcoholists who do not, or do not

often, show signs of intoxication ; and it appears

whenever for any reason the patient has failed to

obtain his usual allowance of alcohol—more especially

of course when all alcohol is suddenly withheld. It

has a close relation—indeed, it is directly propor-

tionate—to the degree of tolerance of alcohol which

has been acquired ; for it is an index of the want of

a drug to which the system has long accustomed

90 ON ALCOHOLISM

itself. It is thus a subjective sudden abstinence pheno-

menon of chronic alcoholism, herein differing entirely

from the dipsomaniac craving which invariably pre-

cedes or depends directly upon the consumption

of alcohol.

Looking clinically at the two cravings, one is struck

with the bearable character of the alcoholic, as com-

pared with the dipsomaniac craving. Many a chronic

alcoholist through a simple effort of will (perhaps

suggested by a small wager with a friend) has suddenly

cut himself off from all alcohol, although, as will be

later pointed out, his success may lead directly to an

attack of delirium tremens : I have histories of several

such occurrences. The dipsomaniac craving, on the

other hand, is never, so far as I am aware, so inhibited,

at any rate, after the first indulgence, although the

danger of serious complications resulting would be

nil : in its marked examples, at least, it seems to be

absolutely uncontrollable. Though the differences

between the two cravings are obvious even to the

untrained observer, it is difficult to define them on

paper. The dipsomaniac craving is, I think, best

described as a pathological passion: it is essentially

impulsive. The alcoholic craving lacks the impulsive

element : it may be likened to the strong desire for

food which assails the grossly underfed or incipiently

starving.

The differences become enhanced when we observe

the effects of the administration of alcohol in these

two cravings respectively. In both, it is true, there

is relief for the moment ; but with the dipsomaniac

the relief is evanescent and rapidly followed by a

very manifest increase in the craving. With the

DIPSOMANIAC AND ALCOHOLIC CRAVING gi

chronic alcoholist, on the other hand, the relief is

enduring, and enduring in proportion to the size of

the dose. Moreover, the chronic alcoholist obviously

improves in all ways, and returns for the time being

to something approaching his normal condition of

physical and mental well-being. The very opposite

is true of the dipsomaniac.

The differences in the character and behaviour

under the administration of alcohol, of the two crav-

ings, have an important bearing on therapeutics

(P- 234).

CHAPTER IV

Symptoms and complications—Acute complications, mental and

other— Chronic mental complications— Alcoholic peripheral

neuritis— Alcoholic albuminuria — Hepatic complications—Gastric catarrh and vomiting.

The ordinary symptoms of alcoholism (whether

intermittent or continuous) are too well known to

call for detailed enumeration and description. But

a few popular fallacies may be referred to.

It is widely believed that alcoholists of all kinds

carry about with them the stamp of their habit in

their appearance. With infrequent exceptions this

view is incorrect. One has only to glance during

meal times round the sanatorium dining-room, where

frequently twenty or twenty-five patients are seated,

to realise the falsity of the general idea. The inter-

mittent inebriate (dipsomaniac, pseudo-dipsomaniac),

except during a paroxysm—when the symptoms of

his condition are obvious to all—shows no sign of

alcoholism : he is in all respects an ordinary, and

generally a healthy-looking, individual. It is only

the chronic alcoholist (whether inebriate or not)

whose face is liable to betray him ; and even he

escapes such betrayal in quite nine cases out of ten.

Moreover, in the tenth case, the facial signs—con-

sisting for the most part in congestion of the con-

junctivse, cheeks and nose—are most commonly

SOME POPULAR FALLACIES 93

temporary, and disappear almost completely within a

week or so after the patient has ceased to take

alcohol. There are, it may be admitted, cases of

acne rosacea in which alcohol is the chief factor, and

in which the eruption pales, and the turgidity of the

new tissue abates progressively as abstinence is

persisted in. But against these must be placed at

least an equal number of cases of the same affection

in which the eruption rather increases than otherwise

in the same circumstances. Moreover, in quite a

number of cases, eruptions of various kinds, simple

acne, eczema, and others, absent during steady

alcoholic indulgence, appear, or more often re-appear,

when abstinence has been practised for a few weeks.

In both cases the cause is the same, namely, the great

improvement which takes place in appetite and in

the processes of digestion and absorption. For it is

undoubted that frequently skin affections depend, not

so much upon dyspepsia, as upon eupepsia—upon

the digestion and absorption of an excess of food,

more especially of rich carbohydrate food, and par-

ticularly sugar. Even acne rosacea occurs not rarely

in lifelong abstainers from alcohol, and in those whodo not suffer from dyspepsia.

Another common fallacy is the belief in the fre-

quency of morning headaches after a heavy carouse

on the previous night. Fulness and throbbing, a

feeling as if the head were about to burst open, and

other less easily described sensations are doubtless

common ; but none of them amounts, except rarely,

to pain or even ache. Of course the alcoholist, like

everyone else, is liable to headache. But he does not

suffer in this particular way more than the average

94 ON ALCOHOLISM

individual. Indeed, it has often seemed to me that

on the whole he suffers less ; and certainly he suffers

less than the anaemic and neurotic woman. More-

over, cases occur in which he suffers only when an

abstainer (p. 133).

Acute Complications, Mental and other.

Amongst the complications of alcoholism, NormanKerr refers to several acute affections, e. g. acute

alcoholic gastric catarrh, acute alcoholic nephritis

with dropsy and convulsions, acute jaundice, acute

alcoholic pneumonia, acute alcoholic insanity, includ-

ing acute mania and acute melancholia ; and acute

alcoholic paralysis. The majority of these must, I

think, be exceedingly rare : most, at any rate, have

been quite absent from the 744 cases admitted into

the sanatorium during the last six and a half years.

No case of acute jaundice, nor anything approach-

ing acute nephritis, has occurred. Only two cases of

pneumonia have been treated, and in neither could

the attack be ascribed even indirectly to alcoholism.

Cases included by Kerr under the head of " acute

alcoholic mania" have occurred; but to these the term" insanity " hardly seems applicable. Acute alcoholic

mania, often termed mania a potu, is, I believe, always

the direct result of alcohol acting on a subject whois for the most part an abstainer. And in the few

cases in which " this mental riot affects continuous

inebriates, the neurotic storm is most easily provoked

after an interval of abstinence " (Norman Kerr),* that

is, of course, in patients who have changed their form

of inebriety—who, from being continuous, have* ' Twentieth Century Practice of Medicine,' 1895, p. 12.

MENTAL COMPLICATIONS 95

become intermittent drinkers. It consists in a

" mania of violence, a maniacal delirium, with little

or no muscular tremor or hallucination."* Mania a

potu seems simply a form of drunkenness, and is

referred to in these pages as hysterical or maniacal

drunkenness in accordance with the mildness or

severity respectively of the abnormal mental mani-

festations. Probably all such cases may safely be

regarded as examples of " pathological drunkenness "

(p. 127) : the abnormal effects of the alcoholic

poison certainly depend upon the personal factor

—

upon an abnormal condition of the patient's brain.

Two cases of acute melancholia have occurred, but

in both the mental disturbance followed—did not

complicate—a dipsomaniac paroxysm : the melan-

cholia might be regarded as a sequel : it commencedonly when the alcohol ceased to be taken. Here,

too, the personal factor was undoubtedly to blame in

the main : in both cases there was a marked history

of insanity in the family.

By most writers delirium tremens and alcoholic

epilepsy would be included under the acute compli-

cations of alcoholism. Here they are excluded in

accordance with the view to be elaborated later

(p. 154), that they result from the too sudden with-

drawal of alcohol from the nervous system, and are

consequently but indirect results of the alcoholic

habit.

Chronic Mental Complications.

On the other hand, mental disturbance, certainly

due very largely to alcohol, but of a chronic or quite* Ibid.

0,6 ON ALCOHOLISM

subacute form, has been observed not infrequently.

The commonest was a mild dementia ; and by far the

most constant symptoms were extreme loss of

memory, especially for the most recent events, loss of

power of concentrating the attention, and absence of

all interest in current events.

Alcoholic Peripheral Neuritis.

There has been no case in the sanatorium of

alcoholic paralysis which could be regarded as acute.

Those classed as toxic or alcoholic neuritis, which

have been associated with distinct motor paralysis,

could be regarded only as chronic, or, at most, subacute.

The signs and symptoms of this affection are

described in text-books so exhaustively as to render

further description here superfluous. Stress, how-

ever, may be laid on the fact that severe cases

have been comparatively infrequent. It is not in-

tended to suggest that the disease is rarer than is

generally supposed : probably the infrequency of

cases admitted is explained by a process of selection,

by the view (which, it may be mentioned inci-

dentally, is quite mistaken) that the sanatorium is

not prepared to admit very serious cases requiring

constant nursing. Amongst the few cases of severe

peripheral neuritis admitted I select the following

:

it seems fairly typical as regards its history,

symptomatology, and I fear as regards its ultimate

result.

Case of severe Peripheral Neuritis due to Chronic Alcoholism.

A highly educated widow, aged 40 years, had been

engaged for some years in assisting her husband in his

FATAL PERIPHERAL NEURITIS 97

literary work. The two were in the habit of working late

into the night, and " to keep themselves going " were

accustomed to take whiskey and soda at intervals—intervals

which, as time went on, became progressively shorter :

they never became intoxicated. Eighteen months before

her admission her husband died suddenly in her arms.

She then went to live quite by herself in a cottage in the

country, and, owing to grief and loneliness, greatly in-

creased her alcoholic intake (up to about a bottle of whiskey

a day). For the last twelve months she had suffered from

marked symptoms of peripheral neuritis. A fortnight before

admission she had an attack of delirium tremens, pre-

cipitated by gastric catarrh. On admission she had been an

abstainer for one week. There was almost complete loss of

power in the lower extremities. The muscles were greatly

wasted : there was foot-drop, and the legs were flexed on the

thighs : extreme pain in the soles of the feet, especially at

night, and hyperesthesia from the knees downwards : the

feet were cedematous and shapeless, knee-jerks nearly

absent, other reflexes mostly exaggerated. Occasionally

there was enuresis, a symptom stated to be extremely rare

There were no mental symptoms, except a tendency to

emotionalism and hysteria. Pulse 128, rising to 140,150,

and even 160 on slight exertion, when there would be a

decided tendency to syncope. The maximum systolic

blood-pressure was 96 mm. Hg.

She proved to be intolerant of strychnine, which, even

in quite moderate doses, caused intensely painful muscular

contractions effectually preventing sleep. Under bromide

of sodium and digitalis, with veronal in 15- and 20-grain

doses at night, there was some improvement in her general

and circulatory conditions. She remained but a few weeks

in the sanatorium, and was then transferred to a hospital

for diseases of the nervous system.

About a month later she died suddenly, as her husband

had done. In her case it seems fair to conclude that the

neuritis had involved the pneumogastrics.

7

98 ON ALCOHOLISM

In the above case, excluding the one attack of

delirium tremens, the mind remained unaffected

throughout. Severe peripheral neuritis, associated,

as so often happens, with gross mental disorder, is

exemplified in the following case

:

Severe Peripheral Neuritis with Prolonged Mental Disorder.

A married man of means, aged 30 years, had been

drinking heavily all his adult life, very heavily since his

marriage five years previously. He drank continuously to

the extent, according to his wife, of at least two bottles

of spirits every twenty-four hours. On admission he was

emaciated and crippled, bed-ridden in fact. He had lost

the use of his lower extremities, the muscles of which were

greatly wasted : there was foot-drop, and evidently pain and

great tenderness in his feet. Knee-jerks absent : other

reflexes somewhat exaggerated. He was quite delirious,

having no knowledge of his surroundings, and obviously

suffering from hallucinations of both sight and hearing.

The male nurse, who had attended him continuously for

a month, stated that four days previously he had three

severe attacks of major epilepsy, whereupon all alcohol was

at once stopped by his medical attendant. Next night he

had a fourth fit ; and during his journey to the sanatorium

in a motor car he first commenced to be delirious.

He remained in the sanatorium a fortnight. Throughout,

he took food well and improved a little physically. But in

order to provide sleep, it was necessary to give hyoscine

hypodermically to the extent of tA-q and even ¥V g r-> at

first every eight, later every twelve hours. He had no

alcohol after admission. When taken home he was still

delirious, but was beginning to realise his surroundings.

Six months later, however, he had not recovered his

sanity.

Some would class this case as one of polyneuritic

POLYNEURITIC PSYCHOSIS 99

psychosis or Korsakow's disease. To me, however,

it seems preferable to speak of it as a case of chronic

delirium tremens. The mental symptoms were indis-

tinguishable from those of ordinary delirium tremens :

they commenced quite definitely, and long after the

development of the neuritic paralysis; and they

were obviously precipitated by the sudden cessation

of the large quantities of alcohol in regard to which

the patient had for years established a high grade

of tolerance (compare the proximate causation of

delirium tremens) (p. 145 et seg.).

Only one other similar case has occured in the sana-

torium. In it, however, the neuritis was hardly more

than incipient (it was purely sensory) ; and the mental

symptoms, though lasting some two or three weeks

in all, completely cleared up before the patient left.

While severe cases of peripheral neuritis have been

rare, very mild or incipient cases have been fairly

common. They have occurred almost solely in

chronic inebriates or chronic alcoholists, more

especially in the latter, in whom intoxication rarely

happens. The symptoms are slight—often so slight

as barely to attract the patient's attention. Theyare usually sensory only, consisting of slight and

occasional fleeting pains and pricking sensations

referable to the limbs, especially to the lower limbs,

and in my experience, more often than elsewhere to

the soles of the feet : such pains always become

exaggerated at night. Also there may be patches

of anaesthesia over the area of distribution of some

special cutaneous nerve, and more rarely a sensa-

tion of coldness, usually subjective, but sometimes

objective also.

100 ON ALCOHOLISM

Now and then cases occur in which there are mild

tabetic symptoms, such as inability to walk steadily

with closed eyes. Less frequently there are symptomsresembling lateral scleroris with increased tendon-

reflexes, and marked intolerance of strychnine.

The prognosis in incipient cases of alcoholic

peripheral neuritis is certainly good : all such have

undergone marked improvement, even during the

short time they have remained in the sanatorium.

Alcoholic Albuminuria.

The subject of alcoholic albuminuria has not

apparently attracted very wide-spread attention in

the medical profession. In Dixon Mann's last

edition of 'The Physiology and Pathology of the

Urine,' reference is made to the albuminuria whichis due to damage done to the renal epithelium by the

passage through it of toxic substances present in the

blood, either autogenous as in diphtheria, or exogenous

as in poisoning by cantharides, phosphorus and

mercurial salts. But no special mention is madeof alcohol. Yet on reflection it must be conceded

that alcohol is by far the commonest of all the causes

of toxic albuminuria. Moreover, it is not difficult

to show that alcoholic albuminuria has important

clinical significances, especially when viewed from

a therapeutic standpoint.

During the years 1909 and 1910, 153* consecutive

male cases were systematically examined for albu-

minuria (women were excluded from the series on* The 153 male cases examined do not of course include all the

male cases examined; they represent merely a consecutive series

examined especially for statistical purposes.

ALCOHOLIC ALBUMINURIA IOI

account of obvious possible fallacies). The urine

was well acidulated with nitric acid, boiled, andallowed to stand for twenty-four hours in a graduated

test-tube, the amount of deposit then being read off.

All the cases were examined on the day of, or the

day after, admission. If there was no albumen

present, no further test was made. Wheneveralbumen was found, the urine was tested every day

or every other day until it completely disappeared,

or until the patient left the sanatorium.

Of the 153 cases, 47 had ceased drinking before

admission, while 106 were still drinking.

Of the 47 who had ceased drinking, 17 showed

albumen, 30 none. It is significant that the latter

had all ceased drinking for five days or more pre-

viously, while the former had abstained for not

longer than two or three days. Of the 17 cases

showing albumen, in 16 the quantity varied from a

mere trace up to 2 per cent. : in all but one of these

the albumen cleared up in the course of a week or so

:

in one it was present at the patient's discharge. In

one case the quantity present on admission was 30

per cent., and on leaving 10 per cent. ; this was

undoubtedly a case of Bright's disease, for there

were many casts.

Of the 106 cases still drinking on admission, in

only ten was albumen absent. Of these 10, one had

been drinking for two days only, having been an

abstainer for several weeks previously: one was

drinking light ale only, and that moderately: five

were drinking for some time, but in some moderation,

but three were drinking spirits heavily.

Of the 106 cases, 96 showed albumen. In 34 of

102 ON ALCOHOLISM

these, the quantity was a mere trace which rapidly

disappeared. In 53 it varied between i and 3 per

cent. ; and in only one of these was it present at

the patient's discharge. In 5 the quantity varied

between 4 and 6 per cent., and in all these the urine

quickly cleared. In 4 the quantity varied between

6 and 20 per cent. ; and only in the one case in which

the quantity amounted to 20 per cent, was albumen

present when the patient left the sanatorium : it had

then, however, fallen to 2 per cent.

From the above statistical analysis, and from large

numbers of cases examined less systematically, both

before and after the commencement and end of the

above consecutive series, certain conclusions (some

perhaps only provisional) may be drawn.

(1) In the majority of cases of alcoholism, albu-

minuria, if carefully looked for, will be found, both

during the time that the patient is drinking, and for

at least a few days afterwards.

(2) In the majority of cases in which albumen is

found, the quantity is small : it varies from a trace to

1 or 2 per cent.

(3) In the great majority of those in which it is

found, the albumen, even when in large amount,

is temporary. As the alcohol is steadily withdrawn

the percentage of albumen steadily falls until it ceases

to be discoverable. There are a few exceptions, how-

ever : sometimes when alcohol is rather suddenly

withheld, there is a temporary increase in the per-

centage of albumen. These cases require further

investigation, and might lead to interesting results.

(4) Other things being equal, the percentage of

albumen varies directly (a) with the amount of alcohol

ALCOHOLIC ALBUMINURIA I03

taken : (b) with the duration of the alcoholic habit

:

(c) with its continuousness : (d) with the strength of

the liquor consumed, spirits of any kind being more

potent than ale, or even wine ; and (e), I think, with

the age of the patient : it seems reasonable to believe

that in early manhood the kidney would be more

resistant to damaging influences than later, and the

facts appear to support this view.

(5) A high percentage of albumen has important

clinical significances. It points almost without ex-

ception to long-continued heavy spirit-drinking, with

few or no intermissions of abstinence, and to the

establishment of a high grade of tolerance of alcohol.

Eight patients who showed on admission 5 per cent,

of albumen and upwards were chronic alcoholists

who rarely or never became overtly intoxicated ; and

most of them presented other objective evidences of

chronic alcoholism. Thus four suffered from peri-

pheral neuritis, one from toxic amblyopia (probably

largely caused by excessive smoking), and two from

gross acne rosacea.

(6) A high percentage of albumen seems especially

to forebode the occurrence of those alcoholic emer-

gencies, alcoholic epilepsy and delirium tremens,

which are prone to arise when alcohol is more or less

suddenly withheld from the chronic alcoholist. One

patient (showing 7 per cent, albumen) had suffered

in the past from seven attacks of alcoholic epilepsy,

and every attack had followed sudden abstention,

whether accidental or intentional. Another (10 per

cent, albumen) had a major epileptic attack three

days after his admission into the sanatorium. Another

(8 per cent, albumen) went through a long and very

104 ON ALCOHOLISM

serious attack of delirium tremens. Two patients

(10 and 5 per cent, albumen respectively) had in-

cipient delirium tremens, which, however, was in

both instances cut short by prompt treatment ; while

three more (about 5 per cent, albumen) suffered

during the process of withdrawal from intense mus-

cular tremor, insomnia, and an unusual degree of

mental misery.

The presence of much albumen in the urine is

regarded by the majority of the medical profession

as an additional or special reason for the withdrawal

of alcohol. This view is, broadly speaking, correct

:

an alcoholist who has severe albuminuria is injuring

himself physically above the average ; and conse-

quently it is specially important for him to become

an abstainer. But a very important qualification

must be made. In all such cases the alcohol should

be cautiously tapered off according to the principles

laid down later (p. 212), never suddenly withheld. In

certain cases in which a high grade of tolerance has

been established, the alcohol has been withheld

suddenly, or what comes to the same thing, has

suddenly ceased to be absorbed through the onset of

gastric catarrh and persistent vomiting. And in

some of these there has been a marked immediate

rise in the percentage of albumen. Concurrently in

a few, there has been a marked fall in the amount of

urine passed, and it is conceivable that in such cir-

cumstances uraemic symptoms might occasionally

develop : in fact, I am inclined to believe that in

one fatal case which occurred some years ago in myown private practice, uraemia arising under the above-

mentioned conditions was the proximate cause of

TAPERING IN ALBUMINURIA 105

death, which was at the time ascribed to chronic

Bright's disease. One case in which a very markedrise in the percentage of albumen followed the com-

plete withdrawal of alcohol is especially referred to

in the chapter on delirium tremens (p. 158). Mean-

while, let it be repeated that a high percentage of

albumen in a case of chronic alcoholism is a special

indication for cautious tapering as against sudden with-

drawal.

The phenomena of alcoholic albuminuria are

occasionally under certain conditions useful for

detective purposes. Take the case of a patient whowas drinking on admission and who showed decided

albuminuria. In the course of a week he has ceased

to take alcohol, and a few days later his albumen has

disappeared. A little later still he is at liberty to

leave the sanatorium grounds and amuse himself in

the neighbourhood. Should albumen reappear in

the urine in these circumstances it is nearly certain

that he is not " playing the game," and has recom-

menced taking alcohol in some quantity. In cases

in whom the albumen has not quite disappeared, an

increase in the quantity may raise the suspicion of

renewed alcoholism, but does not justify any certain

conclusion in that respect : there are many causes for

slight variations in the quantity of albumen passed.

Hepatic Complications.

In considering the pathological action of alcohol

on the organs of the body, it has become natural to

look first of all to the liver ; and amongst the various

affections of that organ, atrophic cirrhosis at once

arises in the mind. But of late doubts have been

106 ON ALCOHOLISM

expressed as to the real frequency of the disease.

Mott, comparing the statistics of hepatic cirrhosis in

general hospitals and asylums, finds the disease

relatively common in the former, nearly absent in the

latter. In the whole of his very large asylum ex-

perience he has met with but one example of very

advanced cirrhosis associated with ascites. Heexplains the discrepancy on the grounds that a large

number of asylum patients who have been inebriates

suffer from intolerance of alcohol, and that such can

very seldom drink sufficient alcohol, extended over a

sufficient length of time, to produce advanced

cirrhosis. Hepatic cirrhosis—the atrophic variety

certainly, the hypertrophic probably—is practically

restricted to the class of chronic alcoholists. As

pointed out by Wilkinson, it is the steady " sober"

drinker, not the habitually drunken person who is the

victim of cirrhosis. A brain sensitive to alcohol is a

safeguard against it ; and so, too, is a stomach which

is readily irritated into catarrh. Hence the inter-

mittent impulsive drinker who continues drinking

until he is unable to retain anything in his stomach

is hardly likely to become affected.

During the last five years at the Norwood Sana-

torium atrophic cirrhosis has been extremely rare

;

there has been no case of ascites, and in only one

case did I feel justified in concluding that the liver

was contracted. It may be, of course, that manycases of incipient cirrhosis were overlooked, but

against this must be placed the absence of distinctive

symptoms of the disease. Now, whatever the real

cause, this infrequency of the complication cannot be

explained, as in asylums, by any preponderance of

HEPATIC COMPLICATIONS 107

patients who suffer from a natural or inherent in-

tolerance of alcohol, for a very high proportion of

the patients admitted suffer from the opposite con-

dition, namely, a very sedulously acquired tolerance

of alcohol ; and it is just amongst such patients that

we should expect to find atrophic cirrhosis. One can

only conclude, therefore, that this well-known, and

constantly looked for, alcoholic complication is con-

siderably less frequent than is commonly supposed.

This is borne out by the statistics of the Inspector

under the Inebriates Acts. For ten years, out of

3300 inebriates, no case of cirrhosis of the liver was

recorded. During the last year, however, there have

been two cases.

There have been five or six cases of chronic

symmetrical and quite painless enlargement with

induration—cases, no doubt, of hypertrophic biliary

cirrhosis ; and in all these there have been slight

occasional attacks of jaundice. In most of them

there has been no perceptible diminution in the size

of the organ during the patient's stay in the

sanatorium.

The only common hepatic affection is slight enlarge-

ment with tenderness, due to congestion. This is

present during the continuance of the drinking and

rapidly subsides when alcohol is given up.

Occasionally, however, cases occur in which the

symmetrical enlargement of the liver is marked : in

which, consequently, there is imminent danger of

concluding that the organ is affected with irreparable

structural disease, but which steadily and rather

rapidly convalesce in all respects under the influence

of abstinence from alcohol, and perhaps other

IOS ON ALCOHOLISM

appropriate treatment. The following case, an

extreme example of this small class, may be of

interest :

Alcoholic Enlargement of the Liver ; Practical Recovery.

A stout man, aged 50 years, a builder by trade, entered

the sanatorium in March. He had been a moderate drinker

until three years ago, when he contracted influenza, which

was complicated by pneumonia and followed by albumi-

nuria. The illness left him weak and depressed, and

resulted in a decided increase in his alcoholism. Theamount of alcohol taken thenceforward steadily rose, until

of late he was drinking little short of a bottle of whiskey a

day: he never became intoxicated.

On admission he weighed 16 st. 41b., he was decidedly

anaemic and had some cedema of the legs, but no ascites

nor any signs of jaundice. He was obviously weak, not

being able to walk more than one hundred yards on the

level without shortness of breath and general distress.

His heart-sounds were normal, pulse 82, blood-pressure 125

mm. Hg. The urine was high-coloured : specific gravity

1018: there was a trace of albumen with a few hyaline

casts, a small excess of leucocytes and a few corpuscles

:

no bile-pigments.

The liver was enormously enlarged, the lower edge

anteriorly being nearly down to the umbilicus : the enlarge-

ment was symmetrical, the surface of the organ smooth.

When the patient was standing the outline was visible,

though the abdomen was thickly covered with fat. The

patient suffered no pain, nor was the liver tender to

pressure.

The ordinary treatment was pursued, except that the

atropine was omitted after a fortnight, and the strychnine

pushed : for three weeks he had up to ^ gr. of the latter

drug hypodermically thrice daily.

Improvement commenced a few days after admission and

CONGESTIVE ENLARGEMENT OF LIVER IOg

was continuous. The albuminuria ceased within five days,

and so did the cedema of the lower extremities. The signs

of anaemia began to recede, and his power of walking

without fatigue steadily increased. But the most marked,

because the least looked for, improvement was in the liver.

The organ commenced to shrink within a. week of admission,

and the shrinkage continued without interruption until the

end of June, when I last made an examination. It would

then have been easy to miss the fact that there was any en-

largement. His own medical attendant estimated that in

the mid-line anteriorly the lower margin of the organ had

retreated upwards 3I in. Taking a normal liver at, roughly,

three and a half pounds in weight, the patient's liver might

have weighed on admission eight pounds, whereas, at the

end of June, its weight would probably not have exceeded

five pounds. At this time the patient himself weighed

14 st. 91b. He is now in fair general condition, but his

blood-pressure has risen to 144 mm. Hg. This is probably

due to the great increase in his intake of food.

The case is of interest from several points of view,

but mainly from that of prognosis. On admission it

was impossible to differentiate the condition of the

liver from the cases of hypertrophic biliary cirrhosis

above referred to—cases in which no material im-

provement was to be expected in a few weeks ; and

indeed my own prognosis was guarded, if not gloomy.

Judging by the outcome, however, it is to be pre-

sumed that the hepatic enlargement in this case,

although so extreme, was due mainly to passive con-

gestion from heart weakness.

Gastric Catarrh and Vomiting.

Vomiting, retching, nausea, etc., are, of course,

common alcoholic symptoms : they are of consider-

HO ON ALCOHOLISM

able clinical importance, since quite frequently they

are the determining cause of an attack of delirium

tremens, or alcoholic epilepsy ; but they do not

always, as is apt to be assumed, depend upon a gastric

catarrh, the direct result of continued irritation byalcohol.

Morning dry retching, probably the most prominentsymptom of the chronic alcoholist, depends, in myexperience, far more upon catarrh of the fauces,

pharynx and trachea than of the stomach. Faucial,

pharyngeal, tracheal, and even post-nasal catarrh are

extremely common in all chronic alcoholists. Duringthe night mucus collects on all the surfaces in-

dicated, and the coughing and other efforts madeon awaking to clear the passages set up so muchextra congestion and consequent irritation, especially

in the faucial area, that reflex retching, often very

violent, ensues. (In the case of an elderly man, withhigh blood-pressure and probably arterio-sclerosis,

morning retching was the immediate antecedent of

an attack of haemorrhagic apoplexy, which provedfatal in a few months.) The symptom may continue

to recur every morning at approximately the samehour for years in patients who shortly afterwards

enjoy a fairly good breakfast and eat two or three

other adequate meals during the day without anysigns of gastric dyspepsia. It is not intended to

deny, however, that some catarrh of the gastric

mucosa may be present even in these cases, and that

such may be so severe as to affect nutrition.

Probably the gastric condition which most nearly

approaches an acute catarrh is that which comes onin dipsomaniacs or pseudo-dipsomaniacs towards the

GASTRIC CATARRH III

end of the paroxysm, and which, indeed, appears

often to be the actual instrument which terminates

the paroxysm. It is characterised by total inability

to retain either solids or liquids, and by incessant

nausea and retching : large quantities of mucus maybe ejected. Even here, however, there is not as a

rule much gastric pain ; nor anything but slight

tenderness on deep pressure over the epigastrium.

The more chronic gastric catarrh dependent onalcoholism is insufficient as a rule to cause vomiting,

except in special circumstances : there is merely loss

of appetite and discomfort after food. Nausea andvomiting, however, may arise either from a heavier

bout of drinking than usual, or from the sudden or too

rapid withdrawal of alcohol. The latter kind occur

only in chronic alcoholists who have established

tolerance. It is not sufficiently recognised. Acommon history is as follows : a chronic alcoholist,

taking something over a bottle of spirits a day, at last

makes up his mind to enter the sanatorium ; but

imbued with the idea that after admission he will be

immediately cut off from all alcohol, makes strenuous

efforts to reduce the amount during the weekprevious. Such efforts are always spasmodic and

usually far too heroic. Probably the patient takes

nothing for twelve hours or so, at the end of which

time he is retching, and perhaps unable to retain

even spirits. Such has been the history of several

cases of delirium tremens.

All such gastric revolts can be prevented by careful

tapering. It is better, therefore, that in all cases of

chronic alcoholism, the tapering process should be carried

out in the sanatorium, not attempted prior to admission.

112 ON ALCOHOLISM

As regards special therapeutic measures to be

adopted at the onset of nausea, retching and vomiting,

nothing in my experience gives such good results as

medical washing out of the stomach. The water

used should be comfortably warm and alkalinised

with bicarbonate of soda ; and as much should be

drunk as can be retained. Should vomiting not be

at once induced, the fauces may be titillated with a

feather or the finger. The procedure may be re-

peated several times, though this is rarely necessary.

The result of emesis is an immediate sensation of

gastric comfort attainable in no other way.

CHAPTER V

Abstinence phenomena of alcoholism—Natural tolerance—Acquired

tolerance; alcoholic insomnia; tolerance of morphine; tolerance

of chloral ; tolerance of veronal ; tolerance of cocaine—Loss of

acquired tolerance—Intolerance;

pathological drunkenness;

mania a potu—Affections arising during and after convalescence

from alcoholism ; recurrent or periodic anorexia ; recurrent or

periodic "bilious" attacks; recurrent sick headache; recurrent

or periodic diarrhoea; recurrent or periodic migraine; morning

headaches;persistent high blood-pressure; acute articular gout.

Alcoholic epilepsy and delirium tremens demand

special consideration, both on account of their great

clinical importance, and because, in the view of the

writer, they stand to the alcoholic habit in a position

which differs essentially from that of the compli-

cations already referred to. The view here taken is

that both these alcoholic emergencies are abstinence,

or sudden abstinence, phenomena of chronic alco-

holism. They are strictly analogous to the symptoms

and complications which arise when a chronic

morphinist is suddenly deprived of his long-

accustomed drug. They depend primarily, of course,

upon long-continued alcoholism, and upon the con-

sequent establishment of alcoholic tolerance; but

proximately they depend in all cases upon a sudden

fall in the amount of alcohol circulating in the blood and

bathing the brain and nervous system generally. They

occur, therefore, for the most part, though not

114 ON ALCOHOLISM

exclusively, in patients, who, in spite of prolonged,

heavy and regular indulgence in alcohol, have either

never or but seldom been overtly intoxicated.

Before bringing forward the evidence and argument

in support of this thesis, it will be convenient to clear

the ground by referring to the technical use of certain

terms, namely, "tolerance, natural and acquired,"

" loss of acquired tolerance," and " intolerance, natural

and acquired."

By "tolerance" is meant the capacity to ingest rela-

tively large amounts of a drug without experiencing

its ordinary obtrusive physiological effects. Toler-

ance concerns many drugs, mostly narcotic : it maybe to some extent innate, but is far more commonlyacquired.

Natural Tolerance.

Natural tolerance is not of any special interest in

this connection. It is a matter of observation that

some individuals, ordinarily abstainers or quite

temperate, are able to consume large amounts of

alcohol without showing the usual alcoholic sym-

ptoms. The condition is spoken of as "constitu-

tional," though that term does not seem to add very

much to our knowledge.

Acquired Tolerance.

This is, on the other hand, of extreme interest and

importance, clinically and otherwise.

Tolerance of alcohol.—In the case of alcohol it arises

in all cases through a long course of steady, uninter-

rupted drinking, the amounts taken being for the

TOLERANCE OF ALCOHOL 115

most part inadequate to produce even incipient

drunkenness, adequate only to cause marked, or

perhaps merely mild, euphoria. The subjects of this

form of drinking attain satiety at this stage : they are

not tempted, therefore, to proceed further, except

perhaps on very special occasions. But as time

elapses, the amount of alcohol necessary to produce

euphoria progressively increases, until eventually, in

the course of years, very large quantities (25 to 35fluid ounces of spirits) may be daily absorbed, andthe patient be suffering from chronic alcoholic

poisoning. Even then he may never have been

intoxicated, and may still be conducting his business

with some success. But he is in constant danger of

severe nervous complications. For a corollary of

acquired tolerance is intolerance of sudden abstinence, or

even, in some cases, intolerance of any sudden large reduc-

tion in the amount of alcohol circulating in the system. Amere temporary abstinence, or large reduction, maygive rise to an epileptic convulsion : a more sustained

abstinence or sustained large reduction may cause

an attack of delirium tremens. And the consequences

may be serious. I know of two patients admitted

into institutions who died suddenly shortly after

sudden withdrawal of alcohol. In one case the

patient cut his throat in an early stage of delirium

:

in the other sudden heart failure occurred apparently

without the intervention of delirium.

Delirium tremens resulting from sudden with-

drawal is very clearly illustrated in a case which

recently came under notice.

An energetic man of business, very successful, aged

Il6 ON ALCOHOLISM

47 years, who had rarely been out of sorts in his life and

never intoxicated, commenced to suffer from gall-stones,

although he had always been, and still was, of exceptionally

active habits. He was lean and muscular, constantly in

hard condition, and to all appearances extremely temperate.

Operation was advised : to this he consented. Accordingly

he entered a nursing home on a Saturday afternoon. Onthe Sunday morning the operation was performed without

a hitch and with entire success. On the Monday morning

there was no rise of temperature, he was very well, and

comfortably reading his newspaper. On Tuesday morning

he became a little irritable and made trivial complaints

against his nurse : throughout the day he did not improve.

That evening he became delirous : when his wife called to

see him he asked her to sit on the bed and keep all other

people away from him, although there were no others

present. At n p.m. he became violently delirious, fighting

with his nurses, who numbered five, and continually calling

for whiskey and soda. His mental condition remained un-

altered until 6 a.m. on Wednesday, when he died from

heart failure.

The operator was probably not fully acquainted with his

patient's habits as regards alcohol ; but these were well

known to his personal friends—especially perhaps his male

friends. He never took alcohol before breakfast. During

the forenoon, he would take one or two stiff glasses of

whiskey and soda : for lunch, one or two more, followed by

a glass or two of port. In the late afternoon he would

have more than one whiskey and soda : at dinner, wine;

and in the evening whiskey and soda again. To sum up,

he would take from 1 6 to 20 fluid ounces of whiskey per diem,

and in addition " appetisers " such as gin and bitters, sherry

and bitters, before, and wine (champagne, hock) during, his

dinner. This course he had pursued for from fifteen to

twenty years : that he presented so strikingly healthy an

appearance he ascribed to his unusually active habits,

wherein he was probably right.

POST-OPERATIVE DELIRIUM TREMENS 117

The patient clearly died from " post-operative

delirium tremens." Concerning such cases, whichconstitute a well-marked group, Mummery says :

" I

think in these cases the partial starvation or altera-

tion in diet necessitated by the operation is moreoften the cause of the delirium than the operation

itself."* Whether this is so, or not, it is certain

that in the case described the delirium commencedat almost the exact time—namely, seventy-two hours

later—that might have been anticipated had the

patient's usual allowance of alcohol been suddenly

withheld when it was withheld, and without any

subsequent operation.

In operations on drug cases (morphine, cocaine,

etc.), it is conceded that the risks are greatly enhanced

if, at the same time, the drug be stopped. It is

advised, therefore, that the drug be continued

throughout the operation period and convalescence

therefrom in undiminished doses.i This plan may be

permissible, and even expedient, in morphinism,

cocainism, etc.—cases in which the drug can be

introduced hypodermically ; and it is, of course,

unavoidable in all cases in which the operation is one of

emergency. But in chronic alcoholism there can be

no certainty of preventing disaster in this way. In

severe cases of this drug habit, very large amounts

of alcohol are often required to prevent the onset of

delirium ; and after general anaesthesia, it may be

quite impossible to get the stomach to retain even

small doses of alcohol. Vomiting, whether merely

nervous or dependent on gastric catarrh, is the com-

* 'After-treatment of Operations,' 1909, p. 22.

t Ibid., P. L. Mummery, 1909, p. 15.

Il8 ON ALCOHOLISM

monest determining cause of delirium tremens in all

those cases in which this complication supervenes

during the continuance of drinking.

There remains, therefore, so far as I know, only

one means whereby in chronic alcoholists post-

operative delirium tremens may be prevented with

absolute certainty, namely, a preparatory period of

total abstinence enduring sufficiently long to cover

the possible onset of this complication. Five or six

days of complete abstinence should be enough for

this purpose ; and where alcoholic tolerance is knownto exist, the period of abstinence should be led up

to by cautious tapering, not instituted by sudden

withdrawal. In these circumstances post-operative

delirium tremens would be impossible.

It is unfortunate, as well as somewhat strange,

that in the case of alcohol the establishment of

tolerance, along with its corollary intolerance of sudden

withdrawal, has attracted practically no attention

from the medical profession. This acquired patho-

logical condition is well recognised with regard to

other drugs ; yet in alcoholism, by far the commonest

of all drug habits, its existence and pathological

bearing are all but ignored. " What are your habits

as regards alcohol ? Are you moderate ? " " Quite

moderate. Why, I have never been the worse for

liquor in my life." Such an answer, so far from

being considered satisfactory—as I know is often the

case—should instantly raise the suspicion of tolerance.

For it is only when tolerance has been acquired that

delirium tremens, post-operative or other, need be

feared.

Stress has been laid on the kind of drinking

ALCOHOLIC INSOMNIA H9

required to establish tolerance of alcohol : it must

be regular, and insufficiently rapid to set up physical

illness, especially gastric revolts. Irregular heavy

drinking leading to frequent attacks of gastric

catarrh, vomiting, and prostration, of necessity leads

to frequent periods of abstinence, whereby any degree

of tolerance already established is lost. Patients

so affected are continually starting afresh. Hence

dipsomania, pseudo-dipsomania, and even chronic

alcoholism, which is frequently interrupted by a day

or two of abstinence, do not tend to establish

tolerance. Also, it may be pointed out that the

possession by a patient of a particularly irritable

stomach readily incited to catarrh is a safeguard

against tolerance, and therefore against delirium

tremens and perhaps against alcoholic epilepsy.

Obviously, too, it is some safeguard against all the

common tissue degenerations which depend upon

long-continued alcoholism.

Short of the grave emergent complications, alco-

holic epilepsy and delirium tremens, which may arise,

whenever the supply of alcohol is inadequate in

patients who have established marked alcoholic

tolerance, a series of easily recognised symptoms

(which are indeed common antecedents of an attack

of delirium tremens) are apt to occur. Amongst

these are nervousness and restlessness, anorexia and

retching, extreme tremor on voluntary muscular

action, and especially insomnia.

Alcoholic insomnia.—Insomnia presents itself in

two forms : (a) an inability to go to sleep : (b) an

inability to remain asleep. Alcoholic insomnia, that

is, the insomnia which especially affects the chronic

120 ON ALCOHOLISM

alcoholist who has acquired alcoholic tolerance, is

usually of the latter variety. Rarely does the patient

experience any difficulty in going to sleep, no doubtbecause he never attempts to do so without taking

several " night-caps." But for years he has awokeearly in the morning. This tendency increases. Astime passes, his initial sleep—the sleep into whichhe falls on going to bed—becomes shorter and shorter

:

when he awakes, he is driven to take more alcohol

if he is to have any chance of returning to sleep.

Eventually, he finds himself with a bottle at his bed-

side, taking " nips " every few hours throughout the

night. And it may be that even then he has never

been frankly intoxicated. The treatment of alcoholic

insomnia is the treatment of alcoholic tolerance.

Tolerance of morphine.—No one questions the

acquisition of tolerance as regards morphine ; and

the sudden or too rapid withdrawal of this drug

has often led to a series of dangerous symptoms.

Collapse has ensued and occasionally proved fatal.

Profuse and uncontrollable diarrhoea leading to

collapse is another not infrequent result : I know

of two cases in which death followed this complica-

tion. But perhaps the commonest sequela is delirium,

which may last a considerable time. One such case

occurred in the sanatorium a few years ago, and it

became necessary to send the patient to an asylum

for some weeks. In this instance it was discovered

afterwards that the patient had taken far more

morphine than he confessed to, and suffered in

consequence from the results of a far too sudden

reduction of the drug. Clifford Allbutt, though he

does not specifically state that morphine delirium

TOLERANCE OF CHLORAL 121

is an abstinence phenomenon, clearly infers as muchin the following two passages :

" Except on withdrawal of the drug we have never

seen the excitement of violence to which the namemorphinomania would be properly applied."* Andagain: "Its (morphine delirium) duration is rarely

more than thirty-six hours : a morphine injection

will probably give prompt relief."?

Tolerance of chloral.—Cushny says :" Prolonged

abuse of chloral leads to a condition somewhat re-

sembling that seen in chronic alcoholism or mor-phinism. The sudden withdrawal of the drug in

these cases has sometimes led to symptoms re-

sembling those of delirium tremens, which are

specially dangerous here, owing to the fatty degenera-

tion of the heart which may be present.! In

consequence, no doubt, of the present unfashionable-

ness of the drug as an hypnotic, there has been but

one case of the chloral habit admitted into the

sanatorium during the last six and a half years. Andcuriously enough, the patient was suffering at the

time from " chloral delirium tremens."

The patient, a married man, aged 44 years, who had

resided until quite lately in New Zealand, had been accus-

tomed to take from 120 to 240 gr. of chloral hydrate, along

with an equal amount of potassium bromide, in each period

of twenty-four hours ; and this for nearly six months

continuously. He had also taken some alcohol—8 or 10

fluid ounces of whiskey. Four days before, he had come

under medical treatment, and both drugs and whiskey had

been largely reduced. On admission in the evening he

* ' System of Medicine,' 1906, vol. ii, p. 956.

t Ibid., p. 955.

% 'Text-book of Pharmacology,' fourth edition, p. 192.

122 ON ALCOHOLISM

was inclined to wander. During the night he became verydelirious and violent, threw his water bottle through thewindow, and tried to wreck things generally. Hyoscine in

dose of -j-^j gr. gave him an hour or two of sleep. Nextday he was quiet. But hallucinations of sight were present(caterpillars, cockroaches, etc.), and only subsided graduallyin the course of four or five days. The hallucinations wereabsent in the morning towards the end, returning in thelate afternoon and evening. Throughout, his physicalsymptoms caused no anxiety : his appetite and digestion

remained good.

Tolerance of veronal.—Of modern hypnotics pro-

bably veronal is most in use at the moment, andthree cases in all of the veronal habit have been

admitted. In one of these admitted last year, the

effect of the sudden withdrawal was seen to be

almost identical with that of sudden withdrawal of

alcohol where a high degree of tolerance had been

established.

The patient, a man, aged 50 years, had been for years a

paroxysmal inebriate, indulging in methylated spirit and

eau de Cologne when unable to obtain other kinds of

alcohol. Under medical treatment, however, he had re-

covered and had abstained from alcohol for six months.

Unfortunately, he had learned that veronal had the power

to reduce irritability and to give mental comfoit when taken

in doses short of those necessary to cause sleep ; and for

some months he continued to take this drug throughout the

daytime in amounts varying from 30 to 60 gr. His friends

noticed that he was drowsy at times, and, suspecting a return

of alcoholism, sought medical advice. In consequence he

was kept in bed in charge of a nurse and was unable to

indulge further in veronal. For the succeeding week he was

sleepless, nervous and excited, and found he had lost his

TOLERANCE OF COCAINE 123

power of speech to some extent. At the end of a week he

appeared to be improving, but quite suddenly becamemaniacal, struggling to get out of bed, and obviously suffer-

ing from hallucinations of both sight and hearing. As his

medical attendant said, his condition was one of typical

delirium tremens. At the end of three days he suddenly

became convalescent and has remained well now for over

twelve months.

Tolerance of cocaine.—It is quite common for

morphinists to " fortify " or " sweeten " their in-

jections with small or medium-sized doses of cocaine,

but cocainism pure and simple seems rare in this

country. Only three or four cases have been ad-

mitted into this sanatorium during recent years.

The experience of these, however, suggests that

cocainism occupies a somewhat exceptional position.

Obviously, the possibility of the acquisition of

tolerance as regards cocaine is a fact, since patients

may take 30 gr. per diem and upwards. But the

corollary, intolerance of sudden withdrawal, does not

seem to be markedly true. In the few cases of this

uncomplicated drug habit admitted the cocaine has

been very rapidly withdrawn with no more serious

result than discomfort : certainly nothing resembling

delirium has occurred. It must be remembered that

unlike some other narcotic drugs liable to set up

habits, delirium is often a direct result of each cocaine

injection. Possibly this fact may give the key to the

comparative absence of delirium from sudden

abstinence. On the other hand, it may be that

the cases of pure cocainism admitted were altogether

exceptional.

Only one case of the paraldehyde habit has been

124 0N ALCOHOLISM

admitted. Here the drug was withdrawn in two

days without results other than discomfort. The

case was a mild one, however.

Loss of Acquired Tolerance.

It is essential, in their own interests, that drug

habitues should understand the full significance of

the acquisition and loss of tolerance. A chronic

alcoholist who perhaps for many years has daily

absorbed large amounts of alcohol without betraying

himself, enters the sanatorium and is tapered off.

In six or eight weeks' time he has recovered to the

extent that he is eating and sleeping well, and enjoy-

ing life generally without alcohol. Such a patient

has largely, if not completely, lost his acquired

tolerance of alcohol. Later, perhaps, through somemore or less accidental circumstance, he takes somealcohol. He is then prone to argue that, having

broken his resolution, he may as well be " killed for a

sheep as a lamb." If he does, and is ignorant of the

loss of his tolerance, he may drink to the extent he

was accustomed to do previously. In this event he

becomes violently intoxicated—it may be for the first

time in his life ; and his relatives report that not

only has he relapsed, but that he is much worse than

he ever was before. And this result is ascribed, not

infrequently, though of course quite unfairly, to the

drugs used in the treatment in the sanatorium. I

have known even medical men to argue from this

that drugs, such as strychnine, can so permanently

alter the nervous constitution of patients as to

render them thereafter intolerant of alcohol. Were

LOSS OF ACQUIRED TOLERANCE 125

it necessary to refute this contention, it could be

shown that such intolerance of alcohol frequently

follows a period of detention in a retreat in which

no medicinal treatment is in use.

The comparative intolerance of alcohol which

succeeds a period of abstinence has led occasionally

to death from acute alcoholic poisoning.

A well-known American journalist had established toler-

ance to the extent that he habitually took from one and a

half to two bottles of whiskey a day, and that without

neglecting any of his journalistic duties. But he began to

suffer in his physical health, and determined to become an

abstainer. He was treated, and the treatment was a success.

For a time (six months) he was an enthusiastic temperance

advocate, and eventually wrote a most brilliant article on

alcoholism. On the night of the publication of this article,

however, he was found comatose in a third-rate saloon :

he died within forty-eight hours from acute alcoholic

poisoning. The exact quantity of whiskey which he drank

was uncertain, but it was known not to have exceeded what

he was accustomed to take before his treatment six months

previously.

Morphinists as a class seem to appreciate more

fully the significance of the acquisition and loss of

tolerance, this probably because they are conscious

throughout that they are dealing with a dangerous

drug, not, as many still regard alcohol, an every-day

article of diet. Nevertheless, accidents happen :

A priest had been weaned from morphine, of which he

had taken 10 gr. daily, and remained free for two years.

He contracted a severe cold, and became much depressed.

He visited the chemist who had previously supplied him

with the drug, and requested the usual dose. The chemist,

126 ON ALCOHOLISM

ignorant of the fact that he had ceased taking any, supplied

him. The dose proved fatal.

In another case an ex-morphinist nearly lost her life

through sheer ignorance. She had been weaned from

morphine, which she had taken to the extent of thirty grains

daily, and had taken none for some months. But on the

occasion of an emotional upset she injected a grain or

more and remained comatose for many hours.

Tobacco smoking is now classed by some as a drug

habit, and although tobacco can hardly be regarded

as a narcotic, there is no doubt that tolerance of it is

established, and that sudden withdrawal is apt to be

associated with discomfort. Also, though this is not

so widely known, the acquired tolerance of tobacco

may be lost.

A merchant seaman commanding a large sailing vessel

cleared from Boston to Calcutta. The second day out it

was discovered that no tobacco had been taken on board

for the men. Various substitutes were tried, but nothing

suitable was found ; and the crew were mutinous and

troublesome throughout the entire voyage, which, owing to

head winds, occupied nearly six months. For the last

fortnight, the men talked of nothing but the smoke they

were going to have on arrival. Immediately they were

safely tied up in Calcutta all the crew purchased tobacco

and started to smoke. In practically every case, however,

the effect was to make them extremely sick.

Intolerance.

A natural intolerance of various drugs is met with

occasionally. Three patients have been treated in

the sanatorium who showed this condition in regard

to strychnine : hypodermic doses of ^ g r - caused in

INTOLERANCE OF ALCOHOL 127

them marked physiological effects, spasms, stiffness

of the lower extremities and difficulty of walking.

One or two cases of intolerance of ordinary doses of

atropine have occurred, and one in which the

bromides had to be abandoned.

Intolerance of alcohol leading to what is termed" pathological drunkenness " has attracted consider-

able attention of late in Germany, mainly from the

point of view of criminal responsibility. It seems

most commonly an inborn or natural condition, but

in some cases has undoubtedly followed head injuries.

It is found also in the insane, weak-minded and

epileptic, and some neurasthenic and hysterical sub-

jects. The subject is discussed in a leading article

of the ' British Medical Journal ' for January ist,

1910. Therein reference is made to the work of

Kraepelin and his school, who have demonstrated by

means of an apparatus capable of estimating differ-

ences of one thousandth of a second that there is,

after even small doses of alcohol, a shortening of the

reaction period which intervenes between a stimulus

and its motor response : the normal intervening

period corresponding to psychic elaboration is ex-

punged or nearly so. In the words of Kraepelin,

" This facilitation of motor reaction is the source of

all the unconsidered and aimless, as well as impul-

sive and violent, actions which alcohol has notoriously

produced."

Several typical examples of intolerance of alcohol

and consequent " pathological drunkenness " have

been observed among patients admitted into the

sanatorium. In one very marked case the patient is

a hard-working and very successful tradesman, aged

128 ON ALCOHOLISM

48 years. Possibly as a result of long-continued

over-work he is very subject to insomnia ; and after

a sleepless night, the least worry of any kind causes

intense mental irritability with depression. In this

condition he is driven to take alcohol. But any

alcoholic drink, even in quite moderate amounts,

exerts a pathological influence. On one occasion he

had taken but three small (reputed pint) bottles of

beer, when he committed what might have been a

fatal assault upon his son, to whom he is muchattached.

It is a question whether a majority of those whofind themselves in the police station on Saturday

night are not examples of alcoholic intolerance and

consequent "pathological drunkenness." This, of

course, applies especially to those who are charged

with being drunk and disorderly, and with particular

force to those who are frequently and regularly

arrested. Such persons are not generally over-

burdened with wealth, and frequent " physiological

drunkenness " is by no means an inexpensive amuse-

ment. Certain it is, at any rate, that very many of

the cases entered in the receiving books of the police

station as delirium tremens are nothing of the sort

:

most probably they are cases of "pathological

drunkenness" depending on alcoholic intolerance,

and would be more correctly described as mania a

potu, or as hysterical or maniacal drunkenness. For

whatever the exciting cause of delirium tremens, it is

certain that the essential predisposing cause of that

affection (acquired tolerance of alcohol) is a long and

expensive process, quite beyond the financial resources

of the ordinary police-court drunkard, except in the

MANIA A POTU 129

few who have special facilities for indulgence, such

as barmen, barmaids, potmen and hotel employees

generally. Mania a potu depends upon intolerance of

alcohol, inherent or acquired, and is a direct result of the

consumption of alcohol, often in quite small quantities

:

delirium tremens depends upon a tolerance of alcohol which

is always acquired, and is a direct result of a sudden

inadequacy in the regular supply of alcohol to the blood

and nervous system. Further distinguishing features

are* : In mania a potu (acute alcoholic mania,

maniacal or hysterical drunkenness) the onset is

sudden, without warning, and without previous

muscular tremor : the pulse is strong and bounding :

hallucinations are rare : there are furious but short-

lived rage and homicidal impulses, with a complete

absence of terror : physical signs of illness, such as

white tremulous tongue, nausea and vomiting, are

absent, or extremely rare, and the patient rapidly

recovers his sanity without complications. Mania a

potu is extremely unlikely to be complicated by

albuminuria.

When it has become generally recognised that

delirium tremens occurs only in those who have

established alcoholic tolerance, and is a direct

result of an inadequacy in the supply of alcohol

to the nervous system, there will be no further danger

of mistaking this affection for mania a potu, or

conversely.

Branthwaite divides chronic alcoholists who eventu-

ally come under the care of the State into two classes:

(a) Degenerates, imbeciles, and epileptics ; and (b)

moral and social defectives.

* ' Inebriety or Narcomania,' Norman Kerr, 1894, p. 84 et seq.

9

130 ON ALCOHOLISM

"A marked intolerance as regards the action of

alcohol is present in both the refractory and quiet

class of defectives, very small quantities of drink, nomore than is taken daily without apparent physio-

logical effect by an ordinary individual, being suffi-

cient to cause disorderly and violent behaviour. Ourexperience in this direction has led us to accept the

view that intolerance of the exciting effects of small

quantities of alcohol may be considered a fairly

certain sign of impaired mental equilibrium."* AndMott, who quotes the above, argues " that a person

who can drink to a condition of advanced cirrhosis

of the liver has inherited an inborn stable mental

organisation."! That is to say, hepatic cirrhosis

excludes intolerance of alcohol, and conversely.

The signs of alcoholic intolerance have been thus

summarised by Tomaschny:} Objective—marked

finger-tremor, increased knee-jerks and other deep

reflexes ; inequality of the pupils, and immobility to

light stimulation. Subjective—the unusually rapid

appearance of the usual picture of acute alcoholism,

with false recognition of objects, actual hallucina-

tions, powerful emotional disturbances, with their

corresponding motor expressions, followed by com-

plete recovery and total amnesia for the events of the

period of intoxication. § I am not able to verify or

dispute these observations ; many of the signs have

certainly been absent in some of my cases of

intolerance of alcohol.

* ' Report on Inebriate Reformatories for 1905,' p. 10.

t ' Brit. Med. Journ.,1 November 5th, 1910, p. 1404.

t ' Allg. Zeitschr. f. Psych.,' Bd. lxiii, Heft 5.

§ Quoted in ' Brit. Med. Journ.,' January ist, 1910, p. 37.

indirect results of abstinence 131

Affections arising during and after Con-valescence from Alcoholism.

Delirium tremens, alcoholic epilepsy, and manyminor affections, insomnia, muscular tremor, someforms of mental depression, anorexia, etc., may be

regarded as some of the direct results of the with-

drawal or sudden retrenchment of alcohol. Butthere are many affections which are apt to arise

later on when convalescence is beginning to be estab-

lished, and some which appear only after prolonged

convalescence. Both may be regarded in a sense as

indirect results of abstinence.

It is practically only in cases who have suffered

from chronic as distinguished from intermittent

alcoholism that these affections occur, and the

explanation is simple.

The majority of chronic alcoholists suffer even-

tually from partial or complete loss of appetite, andfrom chronic gastric catarrh or some dyspeptic con-

dition which interferes with the due absorption of

food and with nutrition. When the loss of appetite

becomes marked the patient becomes alarmed ; and

in fact it is this alarm which not rarely drives him to

seek treatment. Within a few days after he has

ceased to take alcohol the appetite returns, and

usually, perhaps a little later, the power of digestion

and absorption. Real appetite being an almost for-

gotten sensation, the patient enjoys it. Partly

through this enjoyment, but more perhaps through

some crude idea of making up for lost time, he is very

prone to over-eat. Moreover, he is especially prone

to indulge to excess in those articles of diet, the taste

132 ON ALCOHOLISM

for which alcoholism is well known to destroy,

namely, sweets, puddings, and rich carbohydrates

generally. He may suffer in consequence from

ordinary dyspepsia after each meal, with acidity,

flatulence, etc., in which case he probably recognises

the need for, and practices, adequate moderation.

But it is rather astonishing to note how frequently the

ex-alcoholist rapidly recovers his digestive power.

Suffering from no post-prandial discomfort, he con-

tinues to exceed. It may be that a rapid increase of

weight is all that occurs, which is no doubt the most

physiological result. But very commonly—and this

especially in those who do not quickly accumulate

fat—he commences to suffer, often at regular in-

tervals, from what must be regarded as a strike or

revolt on the part of the whole metabolic apparatus.

Such metabolic revolts take various forms in accor-

dance with the varying pathological proclivities and

capacities of different individuals. Perhaps the

commonest—certainly the simplest—is what I have

ventured to call recurrent or periodic anorexia.

Recurrent or periodic anorexia.—After some days of

excellent appetite and complete digestive comfort,

the patient suddenly—and usually on waking in the

morning—finds that he has not the slightest desire

for food. His tongue may be a little furred, his liver

slightly enlarged, and there may be a sensation of

fulness in the head, not amounting to headache.

Otherwise he is quite well. The condition lasts for

twelve, eighteen or twenty-four hours, and then

ceases, leaving the patient as he was before the attack.

Should there be no change in the patient's dietetic

or hygienic habits, the attacks continue to recur at

RECURRENT METABOLIC REVOLTS 133

intervals which are occasionally remarkably uni-

form.

Recurrent or periodic " bilious " attacks.—These are

a slight extension of the above. To the anorexia are

added nausea, and perhaps some vomiting, which is

apt to assume a bilious character. The tongue tends

to be more furred ; and there may be some diarrhoea.

Recurrent sick headache.—To the symptoms of the

bilious attack add a rather severe headache of a

throbbing character, which may be either pancranial

or hemicranial, and the attack may well be termed a

sick headache.

Recurrent or periodic diarrh&a.—Here the pro-

minent symptom is sudden, severe, but short-lived

diarrhoea. Any or all of the symptoms above enu-

merated may be present. The diarrhoea usually

wakes the patient during the night : it is always self-

curative.

Recurrent or periodic migraine.—Sometimes, but

not frequently, except in those who already have a

migrainous habit, the symptoms of the metabolic

revolt are typical of true migraine. The headache

may be severe, throbbing and unilateral ; and I have

noted in two cases respectively hemiopia and slight

aphasia.

Obviously it is impossible to draw a sharp

line of demarcation between any two of these

affections : they all graduate by imperceptible

degrees into one another. Hence the names here

applied are very largely, if not purely, arbitrary.

Elsewhere* I have argued that all of them in some

cases are preventable or dispersible by the same

* ' The Food Factor in Disease,' 1905, Longmans Green & Co.

134 ON ALCOHOLISM

dietetic and hygienic measures, in that they depend

upon one and the same fundamental factor—the symp-

tomatic differences between them depending for the

most part upon differences in the individual. Thefundamental factor is the absorption from the

alimentary canal into the blood and lymphof carbonaceous material, especially carbohydrate

material, in amounts which are beyond the capacity

of the organism for physiological disposal—in

more detail, beyond the aggregated capacities of

combustion (carbonaceous katabolism) and fat

formation, etc. (carbonaceous anabolism). Theinferable result is a steadily increasing accumula-

tion in the blood, lymph, liver, and doubtless other

metabolic organs, of carbonaceous material, which

eventually demands and calls into action pathological

or semi-pathological functions adapted to disperse,

directly or indirectly, the accumulated load. Theaffections above briefly described are some—probably

the commonest—of such pathological functions.

To the blood state which necessitates these functions I

have applied the term " hyperpyraamia " (Gr. pureia=fuel)

;

but the exact chemical constitution of the accumulated load

remains uncertain. As regards the accumulation in the

liver (and perhaps some other parts of the organism), this is

in all probability simply glycogen ; and the distension of

this organ with this material, though pathological, is merely

an exaggeration of a well-known physiological condition. It

seems to be present, and to account for many of the

symptoms, in all the affections above described.

The theory of hyperpyraemia (which includes the recog-

nition of glycogenic distension of the liver) is naturally

rejected by those who hold, with Bernard, that the fractional

percentage of sugar which exists in simple solution in the

THEORY OF HYPERPYRjEMIA I35

blood-serum is the sole blood representative of the large

carbohydrate intake and absorption which takes place after

each meal ; for on this view a carbohydrate accumulation

in the blood is impossible, since any carbohydrate excess

in solution would rapidly drain off by the kidneys and appear

as glycosuria. On the other hand, for those who believe

with Pavy* that by far the larger part of the absorbed

carbohydrate is concealed in the blood-stream by being

incorporated with the proteid molecule, the theory of

hyperpyraemia presents no difficulties : it becomes, indeed,

almost a natural corollary.

In any case, however, it is certain that the theory of

hyperpyraemia directly points to the only correct therapeu-

tics of the affections we are discussing. A carbonaceous

accumulation, whether in the blood, lymph-organs or

tissues generally, may be, conveniently and in a physiological

manner, dispersed (1) by increasing the amount of physical

exercise ; or (2) by special dieting, that is, reduction of the

purely carbonaceous articles of diet. In the former case

the rate of combustion is greatly increased, and, con-

sequently, the output of carbonic acid : in the latter, the

rate of combustion and output of carbonic acid remain

almost unaltered, but the deficiency in the fresh fuel supply

permits of the rapid burning off of the offending accumu-

lation : in other words, the income being reduced, the

arrears of expenditure are made up.

In practice it is preferable and easier, because less

irksome to the patient, to operate in both ways. Thefood generally should be reduced, more especially

the sugars and starches, and regular muscular

exercise enjoined between meals. A comparatively

slight change in these two directions is always suffi-

cient to put an end to the recurring paroxysm.

As regards the treatment during a paroxysm, the

* ' On Carbohydrate Metabolism,' 1906, J. & A. Churchill, p. 34, etc.

136 ON ALCOHOLISM

less the better. Simple abstinence from food should

be practised until the appetite returns : if headache

is present and severe, antipyrin or some similar drug

may be given.

Morning headaches.—I have designedly left this

variety of recurrent attack to the last, because it

is best managed by a special variation in the dietetic

and hygienic change. These headaches occur every

morning on awaking, or very shortly afterwards:

when severe they wake the patient early. Anorexia

may be present, but is often absent. They are

rather common during convalescence from chronic

alcoholism, especially perhaps in women ; but they

occur, of course, under many other conditions.

Most of them—at least of those in the sanatorium

—

are hyperpyraemic, and their treatment is simple

and nearly always quickly successful. It is only

necessary to make the last meal of the day at 7 p.m.

a small one, and to cut out from it the sugars and

most of the starchy articles of food. After dinner,

some exercise (preferably outdoor) must be taken, and

no food—not even a glass of milk—indulged in subse-

quently. Nearly always the patient on the succeed-

ing morning is free from all trace of headache.

The affections above dealt with, all predominantly

metabolic in character, frequently arise for the first

time during convalescence from alcoholism. But

there is apt to re-arise at the same period and in

the same circumstances a long and varied list of

affections to which the patient has been liable in the

past, but which have remained in abeyance, or

perhaps sometimes been merely obscured, during

the period of alcoholism. Among such recrudescent

HIGH BLOOD-PRESSURE 137

disorders may be mentioned asthma, angina pectoris

and skin disease of various kinds, especially acne

and eczema. Asthma, acting as an exciting cause of,

and alternating with, alcoholism, has been referred

to (p. 48). So, too, have acne and eczema during

convalescence from alcoholism, while in a case of

angina occurring in the sanatorium, the fatal

paroxysm was almost certainly determined by a

hearty breakfast, which was one of the first meals

the patient had enjoyed since recovering from an

attack of delirium tremens.

Persistent high blood-pressure.—Whether alcoholism

per se is, or is not, a factor in high blood-pressure is

a moot point. My own belief is that it is not—at

least not an important factor. Though a far greater

number of observations are required before a

definite conclusion can be drawn, chronic alcoholists

have seemed to me to have pressures if anything

lower than the average for their age ; and this would

accord with the action of alcohol as a vaso-dilator,

and as a promoter in the long run of malnutrition

and fatty degeneration of the myocardium. Another

fact seems consistent with the view that alcohol is

a depressor agent. Several patients who whenchronic alcoholists had low blood -pressures, have

steadily developed high pressure during the succeed-

ing years of complete abstinence. The following is

a case in point

:

Case of High Blood-pressure developing after Convalescence

from Chronic Alcoholism.

A country clergyman, aged 43 years, had never been an

abstainer. He had steadily increased his allowance of

138 ON ALCOHOLISM

alcohol, and finally arrived at something over a bottle of

whiskey a day—this without ever having become in the

least degree intoxicated : as he said, "spirits never got into

his head." Two months before admission he had had anattack of delirium tremens lasting four days.

On admission he was rather pale, and, though fat, very

flabby : he had some neuritis in the legs ; and his pulse

was small, soft and compressible. The pressure was not

measured, but it was obviously low, certainly below

120 mm. Hg. As he improved he developed a healthy

appetite, and his digestive power becoming excellent, he

commenced to suffer from a series of " bilious " attacks or

sick headaches : undoubtedly these were largely due to his

neuritis precluding adequate physical exercise.

Nearly four years after leaving the sanatorium he called

to consult me about several attacks he had recently suffered

from ; according to his description these were of the nature

of angina sine dolore. He had remained an abstainer

until two or three months before, since when he had taken

a glass of light hock with his lunch and another with his

dinner. He had put on over 2 st. in weight and had

become florid. His pulse was now large, more sustained,

and not very compressible : measured, the pressure was

152 mm. Hg. He was advised to restrict his diet and take

more exercise ; also to take calomel occasionally and

iodide of potassium in 5-gr. doses thrice daily. Three

months later he wrote to say he had had no further attacks,

and was in excellent health generally.

Acute articular gout.—Amongst patients treated in

the sanatorium recurrent articular gout has several

times ceased under abstinence: this has occurred

most often when the liquors abandoned have been

essentially gout-producing, for example, ales, and

port wine. In one case, however, articular gout,

which had been frequent when the patient was a

ACUTE ARTICULAR GOUT 139

fairly moderate beer-drinker, ceased altogether for

some years during heavy whiskey drinking, but

returned when the patient became a total abstainer.

In this case general restriction of food, especially

the total abolition of luncheon, completely succeeded

in keeping him free.

CHAPTER VI

Alcoholic epilepsy and delirium tremens—Alcoholic epilepsy; cases

occurring in sanatorium ; cases which occurred before admis-sion; conclusions—Delirium tremens; cases occurring in sana-

torium; cases which occurred before admission ; conclusions,

special and general ; differences in incidence between alcoholic

epilepsy and delirium tremens—Alcoholic epilepsy and delirium

tremens combined—Abortive treatment of delirium tremens

—

Some fallacies as to pathology of delirium tremens—Theories of

delirium tremens—Prognosis of delirium tremens and alcoholic

epilepsy—Treatment of delirium tremens and alcoholic epilepsy.

Norman Kerr, by implication, refuses to admit the

possibility of alcoholic tolerance and its corollary,

intolerance of sudden withdrawal. Concerning the

medical treatment of inebriety, he says :" The

alcohol should be at once withheld, and there should

be no compromise with the patient on this point.

The writer has never seen any injury resulting from

this 'heroic' step. 'Tapering off' is inadmissible

with alcohol."* Many medical men hold similar

views.

On the other hand, the general public, including

practically all inebriates and quite a number of

medical men, continue to believe that the sudden

withdrawal of alcohol is fraught with the danger of

producing grave nervous complications. On this

point I place myself, with certain reservations, on

* ' Twentieth Century Practice of Medicine,' vol. iii, p. 51.

ALCOHOLIC EPILEPSY I4I

the side of the general public and the sufferers fromalcoholism.

I propose here to review briefly that part of myexperience during the last six and a half years, whichbears upon the proximate causation of alcoholic

epilepsy, of delirium tremens, and of the twocombined.

Alcoholic Epilepsy.

Since September 26th, 1905, the following cases of

alcoholic epilepsy have occurred in the sanatorium :

Cases of Alcoholic Epilepsy occurring in the Sanatorium.

(1) Married woman, aged 39 years, somewhat obese,

with acne indurata. A heavy drinker of stout, with somewhiskey and brandy. Three days before admission her

liquor was stopped by her medical attendant, with the

exception of a single glass of whiskey as a nightcap. She

was admitted during the forenoon. One hour later while

sitting at luncheon she had a severe attack of major

epilepsy. She had never so suffered before, nor has she

done so since.

(2) Medical man, aged 36 years. For some months had

been taking about 2 oz. of laudanum and nearly three

quarters of a bottle of whiskey a day : never became in-

toxicated. On admission all his whiskey was suddenly

stopped—this at the patient's own request and repeated

insistence, and in spite of the advice tendered to continue

it in moderation for a time : simultaneously his allowance

of laudanum was reduced. Thirty-six hours later, while at

dinner, he had a severe attack of major epilepsy, biting

his tongue rather badly. This was his only attack : it was

not repeated.

(3) Banker, aged 38 years. A heavy spirit drinker for

last six years : rarely intoxicated, and then but slightly :

142 ON ALCOHOLISM

on a few occasions he had been an abstainer, but not for

more than a week. He gave a history of two " fainting

attacks " which might have been of an epileptic nature.

The first occurred after thirty-six hours of almost total

abstinence following an unusually heavy debauch : the second

after fifteen hours of total abstinence following another heavy

debauch. On his admission alcohol was cut off absolutely.

Seventy-two hours later he had a violent major epileptic

attack, biting his tongue severely.

In addition to the above three cases, in which the

epileptic attacks occurred in the sanatorium, patients

have been admitted who had suffered in the past,

and who were able to give clear accounts of the

circumstances in which the attacks occurred.

Cases of Alcoholic Epilepsy occurring before Admission into

the Sanatorium.

(4) Independent gentleman, aged 49 years. A heavy

spirit drinker for many years : had suffered from seven

attacks of alcoholic epilepsy. On every occasion the fit

had come on when, for one reason or another, he had been

without, or nearly without, alcohol for from twenty four to

thirty-six hours. On admission he had been taking about a

bottle of whiskey (26 fluid ounces) a day. This was

reduced to 16, 12, S, 4 and 2 fluid ounces respectively on

successive days. He escaped a fit on this occasion.

(5) Independent gentleman, aged 35 years. For the last

seven or eight years a heavy spirit drinker, rarely becoming

intoxicated, but always taking from 8 to 25 fluid ounces of

whiskey in the day. Two months before his admission

he had an attack of major epilepsy. This occurred on a

Sunday afternoon in Scotland, where he had arrived by train

the same morning, and where he had been unable to obtain

any whiskey. At the time of the fit he had been without

alcohol of any kind for sixteen hours.

(6) Medical man, aged 46 years. Heavy and steady

CASES OF ALCOHOLIC EPILEPSY 143

spirit drinker for the last ten years or so. Only abstainedfive or six times in all, and then only for about a week at atime. He never became perceptibly intoxicated. Hisaverage consumption was a bottle or a bottle and a quarter

a day. Eighteen months ago about, he had three attacks

of major epilepsy, the first and second separated by a

month, the second and third by about three months.Previous to each attack he had cut down his allowance of

alcohol severely for from two to four days : he was, in fact,

making endeavours to give up the habit.

(7) Gentleman of means, aged 44 years, had been" soaking " continuously to the extent of one bottle of

whiskey a day for many months, never, however, becomingthe least intoxicated. He had neuritis in both lower

extremities, and absence of knee-jerks. On Saturday heraised his allowance of whiskey to one and a half bottles.

On Sunday he reduced the amount to half a bottle so as

not to exceed his weekly allowance of seven bottles. OnMonday at 9.30 a.m. he had a severe attack of majorepilepsy, biting the left side of his tongue rather badly : a

second fit occurred in the evening of the same day.

(8) Clerk, aged 38 years, a moderate or moderately

heavy drinker with intermittent outbreaks of drunkenness,

lasting one day only. Had suffered from two epileptic fits

of moderate severity. Prior to the first he had been drink-

ing much more than usual for two days, but on the day of

the fit, which happened in the forenoon, he had, contrary to

custom, gone without any alcohol at all—circumstances

had, in fact, precluded him from obtaining any. Thesecond fit occurred ten months later. He had been drink-

ing "moderately" on Thursday, Friday and Saturday—at

least, on none of these days had he become intoxicated.

On Sunday he abstained completely all day—he was com-pelled to, alcohol being inaccessible. Going for a walk in

the evening, he sat down suddenly and lost consciousness

for some minutes.

144 ON ALCOHOLISM

(9) A married woman, aged 38 years, had been a steady

drinker of wine and spirits all her adult life. She had hadtwo major epileptic attacks. The first occurred ten monthsago at a flower show : whether or not she had cut downher alcohol previously is not now remembered. Thesecond occurred one month before her admission at

8.30 a.m.: just before this attack she was noticed to bevery tremulous : her husband had withheld all alcohol for

forty-eight hours previously.

(10) Married woman, aged 36 years, had been for five

years a steady drinker, but had always been worse—taken

more—on the day before the commencement of the

menstrual period. On the Sunday before her admission

she had gone, quite contrary to her usual custom, all day

without any kind of alcohol. In the evening, without

warning, she became suddenly unconscious, falling downand injuring her head. No similar attack has since occurred.

(11) Miller, aged 27 years, had been in business for

himself for last six years. During that time he had been a

steady drinker, but had not become intoxicated more than

once a fortnight. His usual daily allowance had been eight

to ten glasses of beer, and eight, ten or even twelve nips of

whiskey, the former during the morning and afternoon, the

latter in the evening. Twelve days before his admission to

the sanatorium he had made a sudden and serious attempt

to cease drinking. While on the day previous he had

consumed his usual allowance, he now succeeded in going

all day with nothing but a single bottle of cider. At 9 p.m.

he had a major epileptic fit during which he bit his tongue.

The fit has not been repeated.

Taking the attacks which occurred in the sana-

torium, and adding the attacks which occurred

previously, we have in all 22 fits in n patients. All

were undoubtedly of the variety known as alcoholic

epilepsy : all the patients belonged to the class of

DELIRIUM TREMENS 145

continuous alcoholists; and all had established a

moderate or high degree of tolerance.

The conditions as regards the approximate amountof alcohol taken prior to the fit were unknown in

one case. In the remainder they were known. In

most of the known cases the fit occurred after

periods of suddenly commencing complete abstinence

varying from ten to seventy-two hours; in some, after

periods of suddenly commencing almost complete

abstinence, varying from twenty-four to ninety-six

hours ; and in one, after a period of twenty-four

hours, during which the patient had reduced his

daily allowance of whiskey to something less than

half.

The incidence of alcoholic epilepsy after, rather

than during, a period of drinking, though not often

insisted on, would appear to have been observed.

Gowers, speaking of the uncomplicated convulsions

which are due to alcoholism, says that " in most

cases the attacks occurred after each alcoholic

excess."* And Wernicke states that in his clinic,

" alcoholic epileptic seizures almost always occur

only on the first days following admission."^ (The

italics in both the above quotations are mine.)

Obviously it is on admission that the supply of

liquor is largely retrenched, if not wholly with-

drawn.

Delirium Tremens.

Since September 26th, 1905, eleven cases of

delirium tremens uncomplicated by alcohol epilepsy

* ' Epilepsy,' 1901, p. 22.

t Quoted by Cutten in ' Psychology of Alcoholism,' 1907, p. 249.

10

I46 ON ALCOHOLISM

have occurred and been treated in the sanatorium.

But in the following list three of these cases have

been omitted, because in them strychnine and

atropine injections of moderate size had been

administered from the time of admission, and it

is an open question whether the delirium which

followed was not, in great part, atropine delirium,

or at least delirium tremens precipitated and

modified by atropine (and strychnine?). There

remain, therefore, eight cases for consideration.

(1) Business man, aged 40 years. Heavy spirit drinker

for some years. Took approximately same amount of

alcohol every day : never abstained even for a day : rarely

intoxicated. Admitted on October 2nd, 1905. Next day

very tremulous and nervous. Allowed half an ounce of

whiskey every four hours. Went to bed at 10 p.m., and

slept until 4 a.m. on October 4th. Then he awoke in violent

delirium necessitating restraint. Became rational in forty-

eight hours.

(2) Business man, aged 47 years, admitted on

September 5th. Had been drinking spirits to excess

for many months, and heavily and continuously for three

weeks : often intoxicated. Refused to take any alcohol

after admission. On September 6th and 7th was fairly

well, though tremulous : appetite moderately good. OnSeptember 8th he became nervous and restless during the

day, and in the evening delirious. Became rational in

five days.

(3) Shopkeeper, aged 56 years. Had been taking about

a bottle of whiskey a day for two months. Admitted on

October 9th, having suddenly stopped alcohol two days

previously. Became delirious the same evening, and

rational three days later.

(4) Retired man of business, aged 57 years. Had been

CASES OF DELIRIUM TREMENS 147

taking at the rate of between two and three bottles of

whiskey a day for three months, and this up to the very

hour of admission : often intoxicated. Admitted on

April 27th. Then his allowance of whiskey was im-

mediately reduced to six ounces a day. Two days later

he became violently delirious, but recovered in three days

after a hard struggle.

(5) Married woman, aged 37 years. Had been drinking

heavily for some weeks, often to the extent of two bottles of

whiskey a day. Admitted drunk on August 2nd, 1907.

Allowance of whiskey immediately reduced to three ounces

a day. Next day this was stopped. On August 5th delirium

supervened, and this passed imperceptibly into symptoms

of uraemia, from which she died on August 19th. There

was advanced Bright's disease in this case.

(6) Shopkeeper, aged 47 years. For some months had

been taking three quarters of a bottle of whiskey a day,

together with several glasses of ale : never intoxicated.

Admitted on November 9th, when his allowance of whiskey

was straightway reduced to three ounces a day. On Novem-

ber 1 2th developed a mild form of delirium tremens, which

passed off in twenty-four hours.

(7) Business man, aged 38 years. Heavy and continuous

spirit drinker for some years : intoxicated but rarely

:

drinking up to day of admission, November 13th. Onadmission his allowance was reduced to six ounces of

whiskey daily. Next day uncontrollable vomiting came on :

he was unable to retain even small doses of champagne. OnNovember 15th violent delirium supervened : this passed

off in three days.

(8) Business man, aged 43 years. Heavy spirit drinker

for some months. Never intoxicated. On the day pre-

ceding admission he had two small whiskies only : on the

day of admission, April 4th, none. That night he became

violently delirious, but recovered in twelve hours.

In addition to these eight cases, in which the attack

I48 ON ALCOHOLISM

of delirium tremens occurred in the sanatorium, nine

patients have been admitted who had suffered from

attacks in the past, and who have been able to give

clear accounts of the circumstances in which their

attacks occurred.

Cases of Delirium Tremens occurring before admission into

the Sanatorium.

(9) Retired army officer, aged 57 years, gave the following

history. He had been a heavy spirit drinker for manyyears, and had suffered from seven attacks of delirium

tremens. All these attacks came on when, in consequence

of some slight accident or indisposition, he was unable,

without giving himself away, to procure his usual allowance

of alcohol. During the latter part of his army career he

lived in constant dread of, and took infinite pains to avoid,

being so placed. He was often intoxicated, but never more

than slightly.

(10) Single man, aged 43 years, weighing over twenty

stone. For many years a heavy and steady drinker of spirits,

when able to afford them : at other times, of draught ale :

he often became a little " fuddled," but never intoxicated.

He had suffered from three attacks of delirium tremens : the

first, two or three days after being suddenly cut off alcohol

by the medical man who was attending him : the other two,

when both cash and credit ran out, and he was unable to

obtain either beer or spirits.

(n) Medical man, aged 37 years, for some years a heavy

and steady drinker, usually of spirits, but sometimes of

beer : never became more than a little " fuddled." Had

suffered from one attack of delirium tremens, and narrowly

escaped a second. The developed attack commenced three

days after suddenly ceasing to take alcohol—he had been

taking nearly a bottle of whiskey a day for some months.

The threatened attack occurred about three days after being

CASES OF DELIRIUM TREMENS I49

cut off spirits by the medical man who was attending him :

on this occasion, however, he stipulated that he was to be

allowed Burgundy, and to this—of which he took about a

bottle a day for some days—he ascribes his escape.

(12) Single man, aged 31 years, a heavy and steady spirit

drinker who frequently became "fuddled," but never

intoxicated. Suffered from two attacks of delirium tremens.

The former occurred during " abortive " double pneumonia,

when he was being kept in bed and strictly allowanced as

regards alcohol : the latter, six weeks later, after he had

re-commenced drinking, and was making a futile attempt

to abstain.

(13) Married man, aged 36 years, a heavy and continuous

spirit drinker, who rarely became intoxicated, but often

" fuddled." Had one attack of delirium tremens : this

commenced on the third day after the onset of gastric

catarrh and vomiting, which precluded the taking of either

solids or liquids.

(14) Married man, aged 32 years, for years a heavy andsteady spirit drinker. At first he often became intoxicated,

but this had not happened for some years, although he had,

if anything, increased his amount of alcohol. Had one

attack of delirium tremens, the symptoms of which com-

menced on the fourth day after the onset of severe gastric

catarrh, with constant epigastric pain and almost constant

vomiting.

(15) A successful man of business, aged 44 years, had

gradually in the course of years increased the number of his

whiskey and sodas which he took at his club and at home,

until he found that he was taking rather more than a bottle

of whiskey in the twenty-four hours. The amount frightened

him, although he had never been in the least intoxicated.

Accordingly he suddenly made up his mind to become an

abstainer, which he did on Sunday night. On Monday he

was very nervous and retched all day. On Tuesday he

went to business, but continued to retch at times : he was

150 ON ALCOHOLISM

also very restless and nervous. On Wednesday he remained

at home in much the same state through the day, but

became " queer in his manner " in the evening. OnThursday he was frankly delusional, recovering next day.

(16) Wine merchant, aged 31 years, brought up to take

alcoholic drinks with meals : took ale at the age of nine.

During last four or five years accustomed to take spirits,

and had steadily but slowly increased his daily allowance :

he drank to keep himself going and enable him to increase

the number of his working hours, especially when over-

worked, as had often been the case of late years. He had

never in his life shown the least signs of intoxication. Hethinks the maximum amount of spirits he ever took in

twenty-four hours would be under a bottle of brandy.

Last year he had several attacks of rather acute gastric

catarrh with inability to retain anything on the stomach :

after at least one of these attacks he suffered from a mild

form of delirium tremens lasting two or three days. About

a fortnight ago he suffered again from delirium tremens,

lasting three days : this also followed gastric catarrh and

vomiting.

(17) A retail chemist, aged 30 years, had been quite

temperate until six years ago. Since then had occasionally

been an abstainer for a few months at a time, but had for

the most part been a moderate or moderately heavy drinker,

with occasional severe outbursts of drunkenness. Has had

two attacks of delirium tremens.

The first at the age of twenty-four. After many weeks of

rather heavy drinking he had an outburst of drunkenness.

This brought on diarrhoea and vomiting, and was followed in

a few days by delirium.

The second attack occurred about six weeks before his

admission into the sanatorium. For the twelve months

previously he had been drinking six pints of beer, with a

little whiskey, every day. He was then attacked with right-

sided pleurisy, sent to bed by his medical attendant, and

SUMMARY OF CONCLUSIONS 151

cut off alcohol at once. On the fourth day he becamedelirious : the delirium lasted three or four days.

We may thus summarise the attacks of delirium

tremens, uncomplicated by alcoholic epilepsy, in

which clear histories of the conditions as regards

alcohol just previously were obtainable :

Occurring in the sanatorium, 8 : occurring before

admission (20 in 9 patients), 20 : total number of

attacks, 28.

Concerning these 28 attacks of delirium tremens

the following points may be noted :

Duration ofprevious drinking.—In one case (5) the

previous drinking is referred to as having lasted

" some weeks ": here, however, the quantity taken

was unusually heavy, often reaching two bottles of

whiskey in the twenty-four hours. In one other case

(3) the previous drinking is stated to have lasted two

months. These two cases probably mark the

minimum duration of previous drinking in the series.

In the remaining 26 cases the duration is stated to

have been three to many months ; or it went into

years.

Character of previous drinking.—Prior to all twenty-

eight attacks the drinking was continuous, that is to say,

excluding the two, three, or four days immediately

preceding the actual commencement of delirium,

there was no day on which the patient was an

abstainer, or nearly so ; and in the great majority of

cases the quantity taken each day was approximately

the same : rarely were there any marked fluctuations

in the quantity taken. Of course, the patients had

not always been consuming the maximum quantity

152 ON ALCOHOLISM

noted. But careful inquiry showed that nearly

always the daily allowance had steadily, but very

slowly, increased from quite moderate amounts up to

the maximum : sudden increases were quite excep-

tional.

The character of drinking described is obviously

just that which is calculated to lead to tolerance of

alcohol—that acquired condition in which large

quantities of alcohol can be taken and absorbed

without leading to the ordinary physiological effects

of the drug. Hence, it will cause no surprise to find

that many of the patients never became intoxicated,

and that those who did were only slightly affected.

Of the twenty-eight cases, in only three did it happenthat the previous drinking led often to intoxication : in

these, the continuous or daily drinking was heavy, but

frequently varied by paroxysms of drunkenness. In

six the previous drinking had led but rarely to drunk-

enness. In seven cases the patients had never in their

lives been in the slightest degree intoxicated : such at

any rate, in spite of being heavy drinkers, cannot be

termed inebriates. While in the remaining twelve, the

drinking had led frequently to a quite mild grade of

intoxication, commonly referred to as "slightly

mixed," or " a little muddled " or " fuddled."

It may safely be asserted that with the exception

of the three cases first mentioned, the degree of

intoxication attained could never have led to the

patients falling into the hands of the police.

Pre-delirious fall in quantity of circulating alcohol.—Prior to the commencement of the delirium, in all

twenty-eight attacks there was a sudden and heavy

fall in the quantity of alcohol circulating in the

DURATION OF INCUBATION PERIOD 153

system : this fall amounted quite often to sudden

cessation as far as concerned the absorption of alcohol

from the alimentary canal.

Sudden cessation occurred in thirteen cases. In

eight of these all alcohol had been suddenly stopped,

usually by the orders of the medical man in attend-

ance, but in some' cases at the patient's request. In

five the sudden cessation of the inflow of alcohol

from the digestive tract was not due to cessation

of drinking, but to persistent vomiting, whether

dependent or not upon gastric catarrh.

In the remaining fifteen cases the patient was

supplied with, and no doubt absorbed, a little alcohol.

In six of these the quantity did not exceed 6 fluid

ounces in the twenty-four hours. In nine the exact

amount was unknown, but the patients were probably

correct in referring to it as " a very little ": one of,

the nine was suffering from pneumonia, another from

pleurisy.

Duration of "incubation period."—The interval

between the sudden fall in the quantity or stoppage

of alcohol and the commencement of the delirium

may be termed the incubation period. The approxi-

mately exact duration of this period was known in

thirteen cases. In one only was it as short as forty

hours : in the other twelve it varied between fifty-six

and seventy-two hours : in more than half it was

quite seventy hours.

In the remaining fifteen cases the exact duration of

the incubation period had been forgotten, but the

patients for the most part referred to it as two or

three, or three or four, days.

It seems probable that the incubation period repre-

154 ON ALCOHOLISM

sents roughly the time required for the alcohol to

escape from the system.

General conclusion.—I am quite unable to see howthe preceding facts can have any interpretation other

than that both alcoholic epilepsy and delirium tremensdepend, primarily and remotely, upon the acquisition

of tolerance of alcohol, and secondarily and proxim-

ately upon a sudden fall in the accustomed quantity

of alcohol circulating in the system, that is, of course,

in the brain and nervous system generally. All the

facts without exception are consistent with this view

:

they are not consistent with any other: above all they

are inconsistent with the view held by Norman Kerr

and others, that the two complications are due to the

direct toxic action of alcohol.

I am well aware that these conclusions are not at

present accepted by the entire medical profession in

this country : many still believe that alcohol may be

suddenly withheld with safety even from the most

chronic of alcoholists. Bearing on this point an

article has quite recently been published by Ranson

and Scott in America.* The article is important in

that it is based on the study of 1106 cases of delirium

tremens, 934 of which occurred in the Cork County

Hospital, Chicago, and 172 in the Massachusetts

General Hospital, and because the conclusions drawn

are definite. The writers state, " As to alcohol,

evidence goes to show that while the question of its

administration in the second stage (the stage of fully

declared delirium) is one still open to discussion, and

by no means as yet settled against its use, it should

* ' Amer. Journ. of Med. Sci.,' May, 191 1, p. 673, and epitomised

in the ' Brit. Med. Journ.,' September 30th, 191 1—" Epitome," p. 45.

EPILEPSY AND DELIRIUM CONTRASTED 155

never be withdrawn from incipient cases (that is, cases

referred to in this work as exhibiting premonitory

symptoms), as such withdrawal greatly increases the

chances of an incipient case becoming delirious."

Differences in Incidence between Alcoholic

Epilepsy and Delirium Tremens.

Although both are abstinence phenomena, yet

alcoholic epilepsy differs in its incidence from delirium

tremens in certain important respects.

(1) It does not, like delirium tremens, occur exclu-

sively in those who have acquired a high grade of

alcoholic tolerance : it occurs occasionally after a com-

paratively short outbreak of drinking in one who was

previously a more or less moderate drinker, and whoconsequently is in little danger of an attack of delirium.

Such cases are, however, exceptional, and it remains

true that fits are far more likely to occur in those whohave acquired high tolerance than in others.

(2) It is apt to occur much sooner than is delirium

tremens, after the cessation, or reduction of alcohol

:

for example, it may occur on the first day of absti-

nence (ten hours was the minimum) whereas delirium

tremens rarely occurs before the third day ; and is

often further delayed. Hence it not infrequently

happens that one or more fits herald, and precede by

two or three days, the onset of an attack of delirium

tremens.

(3) Much less frequently than is the case with

delirium tremens is alcoholic epilepsy preceded by

tremor, insomnia, fear, and other nervous symptoms.

This in all probability depends upon its relatively

156 ON ALCOHOLISM

earlier incidence after abstention : the more ordinary

nervous symptoms have not had time to develop.

(4) When alcoholic epilepsy is associated with

marked muscular tremor, insomnia, and other nervous

symptoms such as seemingly causeless fear, it is

highly probable that an attack of delirium tremens

is impending, and that the fit or fits are preliminary

symptoms.

Alcoholic Epilepsy and Delirium Tremenscombined.

The association of alcoholic epilepsy with delirium

tremens is well known. The following three cases

have come under my notice since my connection with

the Norwood Sanatorium.

(1) Engineer, aged 37 years, a heavy spirit drinker, had

been confined to bed under medical advice for three days

before admission. During this time his allowance of alcohol

had been almost but not quite cut off. On his journey to

the sanatorium, while in the train, he had a severe attack of

major epilepsy. On admission on November 26th he was

semi-comatose, with highly albuminous urine, his skin

intensely cold, his radial arteries tightly constricted. Hewas immediately ordered to bed. Two hours after admis-

sion he had a second epileptic (major) attack. On his

recovery it was evident that he was in delirium tremens.

The delirium typical of delirium tremens passed off during

November 30th, but he remained demented for a week.

The albuminuria proved to be evanescent.

(2) Journalist, aged 36 years, seen in consultation.

Patient had been a heavy and continuous spirit drinker for

some years. On June 15th, on having made up his mind

that he must reform his habits, he cut down his daily

allowance of spirit by about three quarters. On June 17th,

CASES EXHIBITING FITS AND DELIRIUM 157

in the evening at his club, he had an attack of major

epilepsy. On June 18th he entered a nursing home, and

all alcohol was withheld. The following two days were

passed entirely without sleep. On June 21st he became

delirious and remained so until the 23rd, when natural

sleep supervened.

(3) Gentleman, aged 37 years, entered the sanatorium on

April 28th. Although he had been for years a steady spirit

drinker, latterly to the extent of about a bottle of whiskey a

day, he had never in his life been intoxicated. So complete

was his tolerance of alcohol that his wife had not until

recently suspected that he was other than quite a moderate

drinker. Yet there seems no doubt that he had already

suffered from two attacks of delirium tremens. The circum-

stances in which these previous attacks arose are highly

instructive. The first followed an injury. He was thrown

out of a cab and had very slight concussion. He was kept

in bed, alcohol being strictly prohibited on account of the

danger of " inflammation of the brain." Within two days he

was delirious, and went through what, judging from his

wife's description, was a typical attack of delirium tremens.

His symptoms were, however, ascribed to the head injury

by his physician, who was, of course, unaware of the extent

of his drinking habits. The second attack occurred five

months later. He had accepted an invitation to a rather

important social function, and had ceased taking alcohol for

a day before. During a dance he became faint and giddy,

and had to be taken to bed, where he was kept next day.

Bearing in mind his previous attack of brain symptoms, his

physician again interdicted all alcohol. In the course of a

day or so he again fell into a delirious condition, which

pursued a course similar to that of his previous attack. Onthis occasion the delirium was ascribed to the excitement of

the social function acting on a brain already damaged

traumatically in some obscure way. There can be little

doubt that on both occasions the delirium resulted directly

158 ON ALCOHOLISM

from the withdrawal of alcohol. He now began himself to

suspect that alcohol was the primary factor of his attacks,

and determined to seek special treatment. He made up

his mind to enter the sanatorium, but anticipating and

dreading that on admission he would be cut off from all

alcohol at once, he reduced his allowance for two days

previously to about a fourth of what he had been accustomed

to take.* He was admitted in the evening and went to bed

soon after. At my visit (10.30 p.m.) he was asleep and I

hesitated to wake him in order to give him alcohol. Next

day, however, it appeared that he had slept for one hour

only, and although he had some whiskey with him, he

refrained from taking any throughout the night, acting, of

course, on the best of motives. He was now intensely

tremulous, being quite unable to stand or feed himself: his

tremors on voluntary movement were truly convulsive. I

should in this emergency have administered very large

doses of alcohol : unfortunately, vomiting had set in, and

alcohol failed to remain for more than a few minutes in his

stomach. He rapidly became worse. In the evening he

had a severe epileptic fit, and this was repeated twice during

the night. Next morning he was obviously in delirium

tremens. This was prolonged and severe. Only after nine

days was there some return to consciousness, and the termina-

tion of the attack was by slow lysis, not, as is the rule, by

crisis. On the seventh and eighth days of the delirium there

was marked circulatory failure, which seemed to render the

result extremely doubtful. Hyoscine in doses of y^ gr.

repeated every six hours gave an hour or two of restless

sleep, but seemingly made no difference in the duration of

the attack.

The course pursued by the albuminuria in this case was

interesting. The marked rise in the percentage which

succeeded the onset of vomiting, and the consequent absence

* This it may be mentioned was a much heavier reduction than

would have been made had the patient been in the sanatorium at the

time.

ABORTIVE TREATMENT OF DELIRIUM TREMENS 159

of alcohol from the system, was especially well marked. Onadmission, and on the first day of delirium, there was 8 per

cent, albumen : on the second day, 40 per cent. : third, 30

per cent. : fourth and fifth, 15 per cent. : sixth and seventh,

10 per cent. : eighth, 4 per cent. : ninth, the day on which

the delirium ceased, 3 per cent. : on the next two days, 7

per cent, and 5 per cent, respectively : and on the following

day (the twelfth from the onset of delirium) the urine becameclear of all albumen, remaining so thenceforward. No casts

were discoverable at any time throughout the attack.

The above three cases illustrate all the points

already made as regards the causation, remote and

proximate, of alcoholic epilepsy and delirium tremens.

In all three the patients were continuous heavy

drinkers (two were chronic inebriates and one a

chronic sober alcoholist), and in all three there was a

sudden and heavy retrenchment in the daily allowance

of alcohol. The first effect in all was alcoholic

epilepsy : the second, typical and severe delirium

tremens.

The Abortive Treatment of DeliriumTremens.

Further, and to my mind, conclusive evidence that

the proximate factor of delirium tremens consists in

a too sudden withdrawal of alcohol from the system,

is obtained from occasional cases in which it has been

found possible to abort completely bymeans of prompt

and adequate doses of alcohol an attack which, though

still in an early stage, has actually commenced. Twosuch cases have occurred in the sanatorium.

(1) An Army officer, retired on a small pension, had been

living for the last year or so in a nursing home. He was

crippled with peripheral neuritis, and had not been out of

l6o ON ALCOHOLISM

doors for twelve months. He was obese and had granular

kidneys. His only occupations were reading and whiskey

drinking. For years he had taken exactly six bottles a week,

the amount being chiefly determined by the amount of his

pension. He had never been intoxicated.

Before entering the sanatorium, which he did in the

forenoon, he had taken about 5 ozs. of whiskey. Thereafter

he took no more for several hours. At 5 p.m., having had

no alcohol since his admission, he became restless and his

expression altered : his attention wandered and his eyes had

a frightened look. At 6 p.m., after being put to bed, he was

brushing imaginary insects from his face. From 6 to 10.30

p.m. he was given whiskey to the extent of 16 or 17 fluid

ounces : this brought up his intake for the day to its usual

level. At 10 p.m. he was decidedly better. At 10.30 he

went to sleep, and had an excellent night, waking in the

morning in his usual condition. The further course of the

case was simple. His whiskey was cautiously tapered off in

seven days without the occurrence of any further disquieting

symptoms. In this case the patient's health was so broken

down that a severe attack of delirium tremens might easily

have proved fatal.

(2) Tradesman, aged 36 years, had for ten years taken

about a bottle of whiskeydaily with some beer. He frequently

got intoxicated, but only slightly so. On admission he was

sober, bur had taken nearly his usual allowance. On the

succeeding four days he was given 10 oz., 7 oz., 5 oz. and

4 oz. respectively. On the night of the fourth day he slept

badly for the first time since his admission. On the

following morning he was quite delusional. His allowance

was promptly raised to 10 oz., and more than half of this

was given at once. He had much sleep during the day and

succeeding night, and woke the following morning quite

rational. He was " tapered off" during the next three days

without further trouble.

This subject is again referred to (p. 174).

fallacies regarding delirium tremens l6l

Some Fallacies regarding the Pathology of

Delirium Tremens.

Reference has already been made to Norman Kerr's

view that delirium tremens is the direct result of

alcoholic poisoning ; and it has been shown in refu-

tation that at the onset of the disorder there is always

less alcohol in the system than the quantity to which

the patient has been long accustomed. Often, indeed,

the system must be quite empty of alcohol at the

time.

Rolleston says it was formerly supposed that

delirium tremens was due to an interruption in the

course of alcoholic stimulation. He regards this view

as now exploded, and states that " the attack indeed

is often brought on by a bout of harder drinking than

usual. *

No doubt this fact is true—I know of several

examples myself. But it is susceptible of more than

one alternative explanation. A chronic alcoholist

who had rarely been intoxicated, and then only

when away from home and business surroundings,

got very drunk and "gave himself away" badly in

extremely awkward circumstances. So disgusted

with himself and remorseful was he that he straight-

way determined to become an abstainer. He carried

out his intention to the letter, but was attacked by

delirium tremens about the fourth day subsequently.

Another patient, also a chronic alcoholist, normally

kept strictly within the bounds of sobriety, but at a

special banquet exceeded largely. As a result he

developed acute gastric catarrh, with uncontrollable

* Allbutt's ' System of Medicine,' vol. ii, Part I, p. 930.

I I

l62 ON ALCOHOLISM

vomiting, so that even small doses of champagne were

rejected : this was followed by a sharp attack of

delirium tremens. In other cases a drinking bout

heavier than usual has succeeded in persuading the

patient to submit to medical treatment, which in the

majority of cases implies sudden withdrawal of alcohol,

the probable result being the same. In all such cases

—which are common—it is true that the attack of

delirium tremens is brought about by " a bout of

harder drinking than usual "; but this serves to

establish, not to upset, my thesis.

Many argue that delirium tremens cannot be due

to cutting off of alcohol, because patients often " drink

themselves into delirium tremens." Here it will nearly

always be found that the patients drink themselves

into gastric catarrh, or some other variety of digestive

revolt ; and that the consequent failure of absorption

of alcohol is the immediate cause of the delirium.

Again it is argued that many patients already under

careful medical supervision and treatment develop

delirium tremens in spite of the fact that their

alcohol has been " tapered off," not suddenly with-

drawn. This also is true, and it brings up a very im-

portant practical point, namely, the essential principles

of successful tapering. This subject will be fully dealt

with in the chapter on treatment. Meanwhile, it is

enough to point out that tapering, as commonly prac-

tised, is almost entirely futile. The initial reduction

instituted is practically always far too heavy (vide

p. 164). I have the less hesitation in speaking dog-

matically on this point, in that I fell into, and con-

tinued for some time, this error myself.

How do the views of causation here advocated

FALLACIES REGARDING DELIRIUM TREMENS 163

square with the known phenomena of what is spoken

of as " traumatic delirium tremens "—that variety of

the affection which is prone to arise after accidents

and surgical operations—and the delirium tremens

which occasionally complicates acute specific diseases,

especially pneumonia ? Ordinarily it is assumed

with little hesitation that the delirium is determined

by the shock of the accident or operation, or by some

nervous condition analogous to shock in the pyrexial

affections, and it may be freely admitted that it is

impossible absolutely to exclude the operation of such

factors. But is there any necessity for importing their

operation into the causation at all ? It is certain

that in practically all these cases sudden retrenchment

or withdrawal is practised concurrently, and manyconsiderations point to the latter as the sole deter-

mining factor. For example, delirium may follow

quite trivial injuries from which the element of shock

is absent. There is no constant relation between the

incidence of delirium and the severity of the acci-

dent. There is, on the other hand, a very constant

relation between the incidence of the delirium and

both (a) the severity and duration of the ante-

ceding alcoholism, and (b) the suddenness of with-

drawal. Again, there is the significant fact that the

onset of delirium is never immediately after the

accident, when the influence of shock might be

supposed to be at its height, but two or three days

subsequently : there is, that is to say, the same " incu-

bation period" which is observed when delirium

follows the sudden retrenchment or withdrawal of

alcohol in the medical treatment of the chronic alco-

holist or inebriate who has met with no injury at all.

164 ON ALCOHOLISM

On reflection there appears to be no room left for

the factor of shock.

The argument is applicable equally to traumatic

and pneumonic cases. For it will not be disputedthat in neither of the emergencies referred to is it

usual to allow anything approaching the chronic

alcoholist's every-day allowance of alcohol from the

time of the accident or operation on the one hand,or from the onset of the initial rigor on the other.

At least I can speak from my own experience. I

have passed some twelve years in residence at general

hospitals of some size, and during that time have

necessarily had under my care a goodly number of

cases in which delirium tremens has supervened in

cases of accident, operation, pneumonia, and other

acute affections. But I am sure that rarely, if ever,

have I ordered in any such case more than 8 or 10

fluid ounces of whiskey or brandy in the twenty-four

hours. In so acting I followed the ordinary practice

of the profession, and felt comfortably assured that,

as regards alcohol, I was dealing with the patient

generously rather than otherwise.

And yet, what is the value of such an amount to a

patient who, quite probably, has been absorbing for

years with comfort and without exhibiting any of the

physiological signs of alcoholism 25 or 30 fluid ounces

of spirits in every twenty-four hours ? It certainly

could not be contended even then that there had not

been a large and sudden retrenchment of alcohol in

case. And this, as I have here argued, is all that is

necessary to precipitate delirium tremens in manycases.

It is stated that delirium tremens arises at times

THEORIES OF DELIRIUM TREMENS 165

in the moderate drinker (F. H. Pritchard,* H. J.

Berkley,! Rolleston,t Maudsley)§; and occasionally

cases have been published in which it is claimed that

the patient was a total abstainer. I have no know-

ledge of delirium tremens occurring in total abstainers

from alcohol and other narcotic drugs. As regards

moderate drinkers, it is obvious that " moderate " is

a term which is variously interpreted. An exceed-

ingly common definition of a moderate drinker is

one who rarely or never becomes intoxicated. Andsince many sober alcoholists habitually consumeupwards of a bottle of spirits a day, they may well

suffer from time to time from delirium tremens. As

I have endeavoured to show, it is just such alcoholists

who are most prone to suffer. The fact is that secret

drinking—or rather, drinking, the real extent of which

is secret—is exceedingly common. The patient in

Case 3 (p. 157), who developed alcoholic epilepsy and

severe delirium tremens in the sanatorium, and whohad previously suffered from two attacks of the latter

affection, was for years a secret drinker—so secret

indeed that even his wife regarded him as strictly

moderate; and there can be no doubt that similar

cases frequently occur. In any case, however, it is

certain that the necessity for secrecy determines the

exact kind of drinking that is best calculated to

establish tolerance of alcohol, the which, it has been

argued, is the primary or fundamental factor of

delirium tremens in all cases.

* ' Quart. Journ. Inebriety,' vol. xxii, p. 408.

t ' Mental Diseases,' pp. 259 and 262.

J Allbutt's ' System of Medicine,' vol. iii, p. 867.

§ ' Pathology of Mind,' p. 485.

l66 ON ALCOHOLISM

Theories of Delirium Tremens.

Many theories of delirium tremens have been

advanced. That of Norman Kerr—that delirium

tremens is simply an alcoholic toxaemia—has already

been referred to. Ford Robertson suggests that

delirium tremens results from some secondary acute

toxaemia which is probably bacterial and originates

in the intestinal tract. Liepmann thinks there is a

more or less constant relation between the albumin-

uria and the delirium : when the delirium is intense,

the albuminuria appears : as it recedes, the albumin-

uria disappears. I once thought this myself, but

increased experience has shown that the inter-rela-

tion is by no means constant. It is admitted that

albuminuria is common in delirium tremens. Thus

Fiirstner found it in 40 per cent. : Nacke in 82 per

cent. ; Liepmann in 76 per cent, or in 56 cases, in 40

of which it was transient, in 16 permanent while

under observation : of the latter, 7 proved fatal and

the autopsy showed nephritis. In all the cases of

delirium tremens treated in the Norwood Sanatorium

there has been albuminuria, which, no matter how

marked, was usually transient.

The common concurrence of albuminuria has

suggested the view that delirium tremens is usually

connected with acute nephritis, and that the toxic

basis of the delirium is uraemic—due, namely, to

deficient renal elimination.* Undoubtedly uraemia

may occur in delirium tremens : it was the cause of

death in the only fatal case which occurred in the

sanatorium (Case 5, p. 147). But in the great majority

* F. H. Pritchard, ' Quarterly Journal of Inebriety,' vol. xxii, p. 480.

RENAL THEORIES 167

of cases there is certainly no nephritis, since the

albumen disappears from the urine completely andoften quite suddenly towards the end of, or morefrequently a day or two after, the delirious period.

There is a weak point in all these theories which

seek to throw the blame for the delirium tremens

mainly on the renal organs. Those who have

advanced them lay stress upon the frequency of

albuminuria in delirium tremens. But they seem to

have worked and argued without a control series

showing the frequency of albuminuria in chronic

alcoholists who have entirely escaped delirium

tremens. Now the fact is (as already stated, p. 102),

that albuminuria is practically just as common, if not

on the average quite so severe, in the latter.

It is the chronic alcoholist who suffers from delirium

tremens, and it is the chronic alcoholist who shows

albuminuria. Other things being equal, the longer

and more severe the alcoholism, the more the

albuminuria ; also, the longer and more severe the

alcoholism, the greater the liability to delirium

tremens. Hence it is easy to see why patients with

delirium tremens should on the average show morealbuminuria than those who escape this complication.

But there is nothing to show that the condition of the

kidney which permits of albuminuria is in any wayresponsible for the attack of delirium tremens. Both

depend upon a common cause : they are not neces-

sarily inter-related as cause and effect.

There is one theory, however, which though at

present insusceptible of direct proof, strongly appeals

to me in that it fits, without strain, all the known

acts of chronic alcoholism and its complications,

l68 ON ALCOHOLISM

alcoholic epilepsy and delirium tremens. That is the

theory of Professor Jauregg. In a paper read at the

eighth International Congress at Vienna in 1901,

Professor Jauregg elaborated the theory that the

immediately responsible toxic substance is generated

by alcohol, and is indeed an " anti-alcohol."* This

view is strictly analogous to one which has been

formulated to explain the abstinence phenomena of

morphinism, but which is now stated to have been

disproved! (W. E. Dixon), I know not on what

grounds. It is really only a hypothesis, but it cannot

be disputed that it is more widely consistent with the

facts than any other. By it we can explain :

(1) The acquisition of tolerance—the steadily increas-

ing capacity to ingest and absorb large quantities of

alcohol without showing symptoms of intoxication

or even experiencing much alcoholic euphoria. Just

as the frequent injection of small and increasing

doses of diphtheria toxin into a horse results in the

formation of increasing quantities of diphtheria anti-

toxin, so, it may be supposed, the frequent ingestion

of small and increasing doses of alcohol results in

the formation of increasing quantities of alcohol anti-

toxin, or anti-alcohol. In both instances the anti-

toxin formed succeeds eventually in antagonising the

parent toxin.

(2) The inability of the chronic alcoholist to do with-

out alcohol (p. 81).—This requires little insistence.

According to Jauregg's theory, it depends upon the

anti-alcohol in the system. The chronic alcoholist is

* Cutten's ' Psychology of Alcoholism,' 1907, p. 249.

f ' Practitioner,' 1907, p. 643 et seq.

jauregg's theory 169

suffering from two more or less mutually antagonising

poisons ; and he approximates most closely to a normal

condition when the two are most accurately balanced.

(3) The loss of tolerance after a period of abstinence—This has already been referred to and exemplified

(p. 124). Under Jauregg's theory, it is, of course,

accounted for by the absence of anti-alcohol, which,

with the complete cessation of the alcoholic intake,

ceases to be formed, and becomes quickly—probably

in the course of a few days—eliminated.

(4) The characteristic phenomena of alcoholic insomnia

(p. 119).—By common consent alcohol is a narcotic.

The hypothetical substance " anti-alcohol " must be,

of course, an anti-narcotic. As it becomes formed in

increasing quantities, increasing doses of alcohol are

required to neutralise its physiological action.

(5) The special—if not exclusive—proneness of delirium

tremens to occur in those who have established a high grade

of tolerance of alcohol.—It would, of course, be in such

patients that the largest amount of "anti-alcohol"

would have been formed in the system.

(6) The onset of delirium tremens after a definite

interval following the sudden retrenchment or withdrawal

of alcohol.—As the amount of narcotic alcohol in the

system progresively falls, the anti-narcotic anti-

alcohol becomes less and less neutralised, and conse-

quently exerts more and more pathological influence.

During the incubation stage of delirium tremens in-

creasing insomnia is the general rule. Finally the

onset of the actual delirium coincides pretty accu-

rately with the time when the system would have

been practically cleared of alcohol.

(7) The symptoms and course of delirium tremens.—

17° ON ALCOHOLISM

When we refrain from masking them by alcohol or

other narcotic drug, the symptoms peculiar to delirium

tremens seem highly suggestive of poisoning by a

substance having an action diametrically opposed in

most respects to that of alcohol. There is, of course,

disordered cerebration in both delirium tremens andalcoholic intoxication. But there the resemblance

ends. In intoxication there is euphoria: in delirium

tremens extreme misery. Intoxication renders the

coward rash, if not courageous: delirium tremens

turns the brave man into a poltroon for the time

being. He may commit violent assaults, but suchare always dictated by terror.

Again, the greater the degree of intoxication, the

greater the tendency to narcotism or coma: the

opposite is true of delirium tremens. Indeed, in this

disorder the resistance to narcotics would seem to

reach its climax. Hypnotic drugs, to be efficient,

have to be given in doses which are little short of

dangerous (Norman Kerr).

The course and termination of the disorder are

again suggestive of poisoning by an anti-narcotic

substance. Left to itself, delirium tremens runs a

course of fairly definite duration, and almost invariably

ends by the crisis of sleep. On the other hand, there

seems to be no doubt that we may greatly modify the

violence of the delirium by the giving of alcohol, but

at the same time we defer the crisis, and so prolong

the duration of the disease. This is, of course,

exactly what we should anticipate on the preferred

hypothesis. The duration of the attack is concurrent

with the elimination from the system of the anti-

PROGNOSIS 171

alcohol. Roughly this is equal to the duration of the

incubation period. Therefore, assuming the truth of

Jauregg's theory, the time required for the elimina-

tion of the alcohol would be about equal to that

required for the elimination of the anti-alcohol.

Prognosis in Delirium Tremens andAlcoholic Epilepsy.

Nothing in connection with the cases of delirium

tremens which have occurred in the sanatorium seems

to suggest any new ideas as to the prognosis of the

complication. The great majority of cases treated

without alcohol or large doses of hypnotic drugs ran

a natural course, and ended by crisis in prolonged sleep

within four days from the commencement of the

delirium. The presence of albumen in great quan-

tity is doubtless an index of severity, and so, too, is a

more than quite moderately raised temperature (e. g.

ioo° F.). The state of the heart and circulation is,

of course, the chief prognostic feature ; and prolonga-

tion of the attack beyond four days is certainly serious

whether as regards the danger of death, or of prolonged

mental alienation.

As regards alcoholic epilepsy, it seems to be unde-

cided whether or not this complication ever leads to

ordinary recurrent epilepsy ; at least, I have several

times been consulted on this point, not only bypatients and their friends, but by their medical atten-

dants. Now it is obvious that alcoholism may lead

to alcoholic epilepsy in one who has a strong inherent

tendency to essential or " idiopathic " epilepsy ; and

it is conceivable that in such a case alcoholism might

172 ON ALCOHOLISM

determine the epileptic habit. A few patients

suffering from essential epilepsy have been admitted

for alcoholism, but in all these the epileptic affection

had preceded,—in some it had seemed to determine

—

the alcoholism. In no case has alcoholic epilepsy

led to subsequent fits except when the original causa-

tive condition has been reproduced. But the

evidence does seem to show that when once alco-

holic epilepsy has arisen, there is an increased ten-

dency for the same complication to occur at subsequent

relapses into alcoholism. I have felt justified, there-

fore, in promising these patients future immunity

from epileptic attacks, always provided they remain

total abstainers.

On reviewing the cases of alcoholic epilepsy above

detailed, it seems almost a pity to use the term" epilepsy " at all. Certainly the fits are for the most

part indistinguishable from ordinary attacks of major

epilepsy, except as regards the circumstances in

which they arise. But these circumstances are dis-

tinctive. Moreover they seem to suggest that the fits

are analogous, not to the fits of " idiopathic " or

essential epilepsy, but rather to the convulsions which,

especially in children, are apt to take the place of the

initial rigor and usher in an attack of pneumonia or

any of the acute specific fevers—to which convulsions

the term " epilepsy " has never been applied.

Treatment of Delirium Tremens andAlcoholic Epilepsy.

The treatment of delirium tremens may be con-

sidered under three heads : (i) preventive treatment,

PREVENTIVE TREATMENT 1 73

(2) abortive treatment ; and (3) treatment during the

attack.

The preventive treatment has been already indicated.

It consists in the main in the careful tapering of the

patient's alcohol downwards from the amount of

acquired tolerance : the danger of any sudden large fall

in the quantity during the first two or three days mustbe kept in mind (p. 214). Bromide of sodium in drachm

doses may be given thrice daily ; and it is usually

expedient for the first few nights to administer one of

the ordinary hypnotics, such as veronal or paraldehyde.

In these circumstances (i. e. when careful tapering

is carried out) the ordinary full dose of any of the

hypnotic drugs is always sufficient. The results of

such systematic preventive treatment can be clearly

shown statistically.

From September, 1905, to April, igog, a period of

three and a half years, neither the importance nor the

special method of tapering was fully understood.

During this period there arose in the sanatorium

eight cases of delirium tremens, or counting the three

doubtful cases which might have been solely or mainly

due to strychnine and atropine, eleven cases.

From April, 1909, to September, 1911, a period of

two and a half years, all patients who had established

high tolerance to alcohol and who were still drinking

hard on admission were carefully tapered offaccording

to the principles laid down (p. 213). During this

period, which included, a distinctly larger number of

admissions, there occurred in the sanatorium but one

case of delirium tremens ; and this case undoubtedly

arose through a misconception, being clearly due, as

were those cases which occurred in the first period, to

174 ON ALCOHOLISM

a sudden fall in the amount of circulating alcohol.

This case has been described in detail (Case 3, p. 157).

It has been claimed that even in heavy continuous

spirit drinkers the alcohol may be suddenly withheld

without danger, provided that an adequate dose of anhypnotic drug, such as chloral, is given to insure sleep.

Possibly this is true. But the dose which is adequate

under those conditions is so large that for my ownpart I lack the courage to prescribe it.

The abortive treatment also has been indicated andillustrated by two successful cases (p. 159). For its

success two conditions are indispensable. The attack

must be in the earliest stage, the mental symptomshaving only just started; and the doses of alcohol mustbe adequate—the allowance of this drug must quickly

be brought up to very nearly, if not quite, the amountof acquired tolerance. Anything short of this will

fail and result only in prolongation of the attack of

delirium.

Occasionally delirium tremens in the earliest stage

may be aborted by large doses of other narcotic

drugs : half a grain of morphine hypodermically was

successful in one case. But this plan has frequently

failed, and it is obvious that there is an added and

avoidable danger in prescribing very large doses of

narcotics to which the patient is unaccustomed.

Chloroform anaesthesia has been suggested as a

means of aborting delirium tremens. In one case

(brought into the general hospital with which I was

at the time connected) there was a fracture of the

upper third of the left femur. This was put up in

the ordinary way with extension. But the patient

was violent and tore off his bandages. Accord-

TREATMENT OF ATTACK 175

ingly he was put under chloroform and the whole

lower extremity and most of the trunk encased in

plaster. For this it was necessary to prolong the

anaesthesia for more than an hour. The chloro-

form unconsciousness passed into natural sleep

which endured for some eight or ten hours, and on

awaking the patient was entirely rational, remaining

so thenceforward.

So impressed by the result was one of the medical

men who assisted in this case, that on being called

shortly afterwards to attend a patient suffering from

uncomplicated delirium tremens, he used chloroform

anaesthesia as a means of treatment. The effect was

disastrous, however, the patient after a very few

inhalations dying of respiratory failure. It is but

fair to add that in this case the patient was old,

drink-sodden, and permanently diseased beyond the

average.

Regarding the general management of the actual

stage of delirium, I have little to add to what maybe found in any text-book. The great majority of

cases occurring in establishments set apart for

alcoholism and other drug habits are uncomplicated,

and if merely protected from injury, accidental and

other, pursue a favourable course of three or four

days towards the natural crisis of prolonged sleep

and rapid convalescence. In such, therefore, when

once the chance of cutting short the attack be

passed, it suffices to provide adequate skilled atten-

dants (two at least are always required) who must be

instructed not to allow the patient out of sight for an

instant, and to see that some fluid nourishment is

administered from time to time.

176 ON ALCOHOLISM

But it may happen that (a) the delirium is pro-

longed : (b) the temperature is considerably raised

—

101 F. or more ; or (c) there are signs of circulatory

failure. In all such cases it seems essential that

sleep should be procured. For this purpose, apo-

morphine, as already stated, has hitherto proved

useless in my hands, nor have I had much success

with any of the ordinary hypnotics, except perhaps

hyoscine. The last seems, at present, the mostefficient drug in the circumstances. Beginning ten-

tatively with yfj- gr., I have given up to ^ gr. every

six hours for some days. The usual result is to give

the patient an hour or two of rather disturbed sleep

after each injection. But there is no evidence that

by this means the duration of the delirium is

abbreviated.

While there is no doubt that alcohol carefully

and adequately given almost invariably prevents,

and in certain circumstances may abort, delirium

tremens, it is at present doubtful whether the drug

is of any real use when once delirium is definitely

established—whether, indeed, it is not often in-

jurious. Those who have largely used it hold that

it modifies the severity but prolongs the duration

of the delirium. And my own experience tends to

confirm this view.

The preventive and abortive treatments described

have, as just stated, been so successful that during

the last three years but one case of delirium tremens

has arisen in the sanatorium. But there is at any

rate one complicating symptom which at present

will doubtless operate to prevent such freedom from

continuing. I refer to gastric catarrh associated with

TREATMENT OF ALCOHOLIC EPILEPSY 177

uncontrollable vomiting, which effectually precludes

due absorption of alcohol from the stomach and

upper part of the alimentary canal. In this emer-

gency it has been suggested to give alcohol per

rectum or hypodermically. But by neither route

could an adequate amount be given. There remains

the possibility of administration by inhalation.

Hitherto I have had no chance of testing this

method. But I should certainly not hesitate to do

so in the future whenever the opportunity offered.

There is no special treatment for alcoholic epi-

lepsy. Like delirium tremens, its prevention depends

upon careful tapering. But preventive treatment is,

if anything, less successful in the case of epilepsy,

since the warning signs of an attack are much less

clear (even when they exist), and the incubation

period is often much shorter. When alcoholic epi-

lepsy is a mere symptom of delirium tremens, its

treatment, of course, is the same as that of the major

disorder. Probably in all cases the majority of

physicians would administer bromides in some form.

But there is nothing to show that these drugs have

any material influence on the disorder ; and

commonly they are quite unnecessary.

12

CHAPTER VII

Treatment—Compulsion and Moral Tone—Voluntary restrictions

—

Policy in a Free Sanatorium—Diet—Tobacco.

A medical pioneer whose work has been accepted

exercises an abiding influence on the profession ; and

this applies to some of his expressed views which

have not fully stood the test of time. The late Dr.

Norman Kerr is a case in point. No one will dispute

his sincerity, or the deserved and commanding

position to which he attained in the clinical study of

alcoholism. But that some of his conclusions were

premature there can be no doubt. For example, the

student of his works may be forgiven if he draws the

conclusion that, for practically all cases of alcoholism,

twelve months' confinement in a retreat where

alcohol is inaccessible is the only course likely to be

of any real and lasting benefit ;* and it is certain that

many medical men continue to hold this opinion at

* " In very few cases should a shorter term than twelve months be

recommended. In many cases a term of eighteen months to two

years is indicated. In very confirmed cases three or more years are

required, while some inebriates need seclusion for much longer

periods. . In a few cases a period of nine months, or even

six months, may be freely suggested. In no case have I ever seen

my way to recommend a shorter term than six months. If the cir-

cumstances do not warrant more than three months this term can be

sanctioned, as a matter of necessity, not of choice."— ' Inebriety or

Narcomania,' by Norman Kerr, 1894, p. 394.

INEXPEDIENCY OF SUDDEN WITHDRAWAL 179

the present time. No doubt there are patients whorequire such prolonged seclusion ; and it is probable

that the number was relatively greater when Dr.

Norman Kerr wrote : alcoholism was then only

beginning to be regarded as a province of medicine.

But at the present time such patients are in a

minority—a minority which will become progressively

smaller. For with the diffusion of knowledge, alco-

holists are applying for medical advice in a stage of

their morbid habit which tends to become earlier

every year.

Two convictions of the medical profession have

done much to throw the management of alcoholism

and inebriety into the hands of unqualified and

unregistered practitioners : (i) that nothing but

prolonged enforced seclusion is of any value ; and

(2) that it is essential in all cases to insist uponsudden and complete withdrawal of alcohol.

The former simply operates to exclude the great

majority of those who are in need of treatment.

Quite apart from the question of expediency, the

conditions offered are usually impossible, always

unacceptable. The patient is often the bread-winner

of the family, and a year's absence from his post

means ruin : it is, in fact, only those who are inde-

pendent, or who, on the other hand, are permanently

dependent on relatives or friends, who can comply

with such conditions. To recommend the ordinary

alcoholist to retire into a retreat for a prolonged

period is about as reasonable as to prescribe a

yachting trip for a pauper.

The practice of uncompromising, sudden, and

complete withdrawal of alcohol in all cases is un-

l80 ON ALCOHOLISM

necessary, impolitic and injurious to the best interests

of both patients and the profession. Whether alco-

holism is properly regarded as a disease is still an

open questiun ; but that it conforms to one, at least,

of the canons which govern disease in general there

is no doubt. Other things being equal, alcoholism

is remediable inversely as its duration : hence every

impediment, real or fanciful, in the way of early

treatment should be removed. The chief impedi-

ment—compared to which all others sink into insig-

nificance—is the terror of sudden withdrawal. In

severe cases, the chronic alcoholist (like the chronic

morphinist) lives in constant terror of finding himself

so placed as to be unable to procure his accustomed

narcotic in adequate amount, feeling assured that in

such circumstances he would be more than threatened

with some grave nervous complication. How manytimes has the remark been addressed to me—" HadI known you would not have cut me off suddenly I

would have come to you years ago " ? And the

manifest relief of patients when they find that they

are going to be " let down lightly " is at times almost

pathetic. Personally, I have no doubt that sudden

withdrawal is in some cases often a dangerous pro-

ceeding. That, however, is a contentious question

which need not again be raised. What I wish to

emphasise here is the gross inexpediency of the

practice. By insisting on it in all cases, the super-

intendent of a " free " sanatorium would inevitably

lose many of his most promising patients.

The Norwood Sanatorium may be regarded as the

outcome of the recognition on the part of the medical

profession that the licensed retreats, excellently

COMPULSION AND MORAL TONE l8l

managed as many of them undoubtedly are, do not

meet all the requirements of a very large class—in

my view the large majority—of alcoholists. Fewcan afford the time for prolonged seclusion. Fewer

still can be prevailed upon to sign away their liberty

under the Act. It may be urged that licensed

retreats are not precluded from accepting patients

for short periods, whether under the Act or other-

wise, and that, in fact, many of the patients in these

institutions are so admitted. But there are objec-

tions—objections endorsed by the Inspector under

the Inebriates Act*—to the mixing in the one insti-

tution of long and short term patients ; and these

objections are especially applicable where some are

under the Act—and may be, in reality, serving a

term of imprisonment for drunkenness—and others

are voluntary patients.

Compulsion and Moral Tone.

In an inebriate retreat in which the majority (or

even some) of the patients are remaining through

legal compulsion, it is impossible to secure the same

moral atmosphere as in a sanatorium where all have

entered voluntarily, and where all are free to leave

at a moment's notice. In the former there are

nearly always some who have given up trying, and

who know that most of the remainder of their lives

will be spent under supervision of some sort : in the

latter all are at any rate hoping for, if not confidently

expecting, more or less permanent relief. The

difference between the two kinds of institution does

* Report for the year 1902, p. 15.

182 ON ALCOHOLISM

not depend upon the personnel of the staff in either

:

it results naturally from the conditions under which

the patients are admitted and remain. You cannot

employ compulsion, and at the same time be sure of

securing the full and hearty co-operation of the com-

pelled in the treatment and management. Sooner

or later compulsion breeds the school-boy spirit.

Outwitting the management is apt to be regarded as

a joke, and the smuggling-in of alcohol with a lenient

eye. I do not say the latter often happens, but the

tendency is there and has to be combatted. Now, in

a voluntary sanatorium the superintendent is never

faced with this difficulty. In the few instances in

which alcohol has been brought in, the patient has

been careful to keep his treasure to himself, for he

well knows he would obtain no sympathy from the

others. Those others would regard him as a general

nuisance, and as a common enemy.

Strictly speaking, there is no compulsion in the

sanatorium, except in the case of delirium and other

mental states in which the patient is irresponsible

:

compulsion in any other circumstances would be

illegal, and therefore impossible. But patients are

informed on admission that they are expected to

follow in all details the advice which is tendered

them, and that in the event of persistent refusal or

failure to conform with such advice, they will be re-

quested to leave the institution. Obviously this is in

their own interests. The right to discharge an

unsuitable patient is the only real power possessed

by the medical superintendent, but it is ample in all

but a very small fraction of the cases admitted.

Since my earliest connection with the sanatorium,

COMPULSION AND MORAL TONE 183

patients with whom I have discussed the subject

have been practically unanimous in expressing the

opinion that the plan of putting them on their honour

is far more likely to prove effectual against the illicit

consumption of alcohol than that of trying to makealcohol inaccessible through legal confinement.

Further, patients who have had experience of

licensed retreats, perhaps, on more than one occa-

sion, have averred that, in point of actual fact, there

was less illicit drinking under the former plan. Fora long time—some years, indeed—I paid little atten-

tion to these views and statements. They seemed

so obviously an example of the wish fathering the

thought. Moreover, one has to be continually on

one's guard against the tendency of patients to makethemselves pleasant to the " powers that be," and

against the facile acceptance of evidence that happens

to fit in with, and confirm, one's own work and

theories.

Of late, however, there have been several patients

whose evidence, coming on the top of all that pre-

ceded, could hardly be ignored. These patients had

all been in retreats, either under the Act, or as volun-

tary boarders, and all had from time to time taken

alcohol, either when away from, or within, the institu-

tions. Yet while in the sanatorium none of them did so,

although they were free to come and go after the first

week or ten days. How account for the difference ?

Personally I ascribe some of the difference to the

regular course of medication pursued in the sana-

torium, but the patients explained things otherwise.

They said :" I have given my word, and intend to

keep it : I am on my honour"; or, " When I entered

184 ON ALCOHOLISM

I made up my mind to play the game"; or again,

" There is no fun in getting a drink when it is so

easy." These explanations afford food for reflection.

Voluntary Restrictions.

An important item in the advice tendered is that

the patient from the time of his admission remains

within the building or the grounds of the institution,

preferably within sight, until such time as it is

deemed safe for him to go further afield. This

period, whimsically termed by patients "being on

the chain," varies in duration. In a few cases it is

not necessary to enforce it : this refers to patients

who have quite ceased drinking for some weeks pre-

viously, and in whom, judging from the history

supplied, it is improbable that an outbreak is im-

pending. But usually it lasts a week, ten days,

or perhaps a fortnight : very occasionally it is

longer.

The restriction is rarely a grievance. Now and

then a patient will complain that his loss of liberty

is annoying. But this feeling ceases at once whenhe is reminded of the fact that there is, and can be,

no loss of liberty : he is merely following the medical

advice and undergoing the medical treatment, to

obtain which he entered, and for which he is

paying.

Regarding such voluntary restrictions of liberty,

the sanatorium course may be divided into two,

sometimes three, periods, all of which vary in length

according to the necessities of the case. The first

period, " on the chain," has been referred to. During

the second period, the patient, usually in company,

VOLUNTARY RESTRICTIONS 185

goes for short country walks, or to the village,

returning, however, for each dose of medicine and

each injection, and missing no meal, not even after-

noon tea. Like the first, the second period varies

in length, but commonly lasts much longer, and,

indeed, often continues to the end of the course.

But the restrictions need not be so severe through-

out : in the latter part a meal may often be missed,

and a tablet taken in place of an injection, etc. Thethird and last period is usually short and not invari-

ably allowed : it covers the final week, perhaps the

final fortnight, and is only common in those whoprolong their stay in the sanatorium beyond the

period of six weeks. The patient may then go

occasionally to London, attending matinees or other

afternoon places of amusement, having made special

arrangements, so as not to miss his medicinal treat-

ment. Visits to theatres, music halls, etc., in the

evening, though permitted at one time, and even yet

allowed in some cases, are not now encouraged.

With the majority of patients the incidental risks

are too great. Of late years there has been an in-

creasing tendency for wives to remain in the sana-

torium while their husbands are undergoing treat-

ment. And in most such cases no doubt the rule

against evening entertainments in London may be

safely relaxed. The same applies, perhaps, to others

who have passed a certain age, or who go accom-

panied by someone in whom the management have

confidence. But for the rest the immediate sur-

roundings of the sanatorium are regarded as the

expedient limits for wandering between late dinner

and bedtime.

l86 ON ALCOHOLISM

All the above remarks apply to the minimumcourse of six weeks. In those cases—all too few,

but steadily increasing in number—in which patients

accept the advice to prolong their course to eight,

twelve or more weeks, the sub-divisions of the course

are modified accordingly.

Policy in a " Free " Sanatorium.

It is manifest that the policy expedient in a free

sanatorium differs widely from that which can be

pursued in a licensed retreat with patients who have

signed away their liberty under the Inebriates Act.

In the former patients are of necessity largely on

their honour : this follows naturally from the absence

of legal compulsion, just as a debt of honour takes

precedence of a debt for which one can be sued.

The superintendent can never forget this fact : he is

forced to act in accordance with it at every turn.

Wherefore he has to avoid the slightest suggestion

that patients are deliberately planning to obtain

alcohol. This is easier than may appear at first

sight. A patient who is obviously unsafe to be left

alone in the proximity of an hotel requests leave to

go down to the village shortly after his admission,

and offers to give his word of honour to take nothing

while away. His sincerity must not be questioned

for a moment ; but it should be pointed out to him,

that although he is ignorant of the fact, he is at

present unsafe : that although he would doubtless

start out with quite admirable intentions, he is still

liable to be assailed, at any moment without any

warning, by an uncontrollable impulse : that a single

POLICY IN A FREE SANATORIUM 187

drink taken in these circumstances wipes out whathe has already gained and means starting over again ;

and so involves loss of his time and his money. It

would then be open, and indeed justifiable, for him

to blame the superintendent for an error of judg-

ment, etc.

This line of argument rarely fails : the patient sees

the point at once, his face is saved, and he is content

to wait, seldom making a second similar request.

Later, in such cases, it is always advisable for the

superintendent to take the initiative and himself

suggest that the time has arrived when it is safe for

the patient to grant himself a greater degree of liberty.

Then, curiously enough, it not very infrequently

happens that he has changed his mind. Realising

his liberty, he takes no advantage of it. He will

often remark :" There is plenty of room here, and

really I think I am safer inside. I now see it is silly

to take unnecessary risks, and am glad you advised

me not to go out before." The fact is his brain

is returning to a normal state, and he is beginning

to see things in their real proportion. Further, he

is ceasing to regard the sanatorium as a kind of

reformatory where personal liberty is restricted—

a

view entertained on their entry by new patients

almost without exception. Question any fresh

patient a week or so after his entry as to his pre-

conceived ideas of the sanatorium. It is no ex-

aggeration to say that quite often he entertained

visions of separate cells, low diet, enforced exercise,

perhaps occasionally a strait-waistcoat, and generally

a more or less penal regime. How such ideas

originated he cannot, nor can anyone, say : possibly

100 ON ALCOHOLISM

they are a survival from the times when inebriety wasregarded as a demoniacal possession to be starved

and driven out of the human being by penances. JAt

any rate, it is certain that the continued existence of

these and similar ideas still preclude many from

seeking efficient institutional treatment. The fact

is that life in the sanatorium is indistinguishable

from life in a large boarding-house or small resi-

dential hotel, with the exception that there is no

wine or other alcoholic liquor on the dining table.

No effort must be spared to avoid wounding the

patient's amour propre. He must be treated as a

responsible and honourable individual. He must

never be ordered : he must be advised. But naturally

it is essential to see that the advice is followed ; and

it is but common-sense so to arrange matters that

this is not fraught with unnecessary difficulties. For

example, a patient who is still drinking hard is

admitted in the late afternoon or evening, and

having been prescribed for is advised to go to bed at

once. Also he is strongly advised to remain in bed

on the following morning until the superintendent's

visit. Now this advice is not nearly so easy to

follow as might be imagined by the temperate

reader : the patient in such circumstances is apt

to suffer from an almost intolerable restlessness

in the early morning. It is expedient, therefore,

to smooth the way for him. It may be that on

his arrival he is badly groomed and sadly in need

of valeting. But the brushing and pressing of

clothes takes time ; and since the patient is to

remain in bed, there is no need for hurry on the part

of the rather busy domestic staff. A clean suit of

TACT IN MANAGEMENT 189

pyjamas and handkerchief are all that need be left

in the patient's room.

There are many means of divesting restrictions of

their irksomeness. For instance, in the systematic

course of treatment by strychnine and atropine the

injections steadily rise to a maximum in dosage, and

then steadily fall ; and it may be suggested to the

patient who is constantly worrying to go out, that he

will be safe in doing so only when the dosage is

reaching its climax or thereabouts ; and such

climax may be quite slowly attained, if thought

advisable. In some such way it is possible to

eliminate the personal element—to prevent the

patient thinking that he is being treated unduly

harshly, or made an exception of, the which he is

prone to resent.

The policy adopted is to give the maximum of

liberty consistent with safety. For example, often

two patients may be allowed out together, when it

would be inexpedient to allow either out alone. Thesafety of the two results from the moral tone

engendered by the absence of compulsion. A patient

by himself might take alcohol, but he would not for

anything be seen doing so by another patient : he

would as soon be seen by the superintendent. Ofcourse there are exceptions : one patient some years

ago seemed to delight in trying to persuade the others

to drink : his stay in the sanatorium was short.

Such cases are extremely rare : in fact, I know of no

other.

Every endeavour is made to explain to each

patient on his admission what the sanatorium can

do for him, and what he must not expect from it.

190 ON ALCOHOLISM

The term " cure " is never employed, not because

there are not many patients on the books who have

remained well since leaving the institution, but

because the term is used in so many different senses

as inevitably to lead to misconception. It is

explained that while in the sanatorium the craving for

alcohol will almost certainly cease and remain in

abeyance ; and further, that except in very special

circumstances, it will not re-arise unless the patient

takes alcohol again. When that has happened, how-ever, all further security will have disappeared.

The majority of patients are on admission fully

prepared for these limitations. But some few have

anticipated more definite results—that after treat-

ment they would be able to do what had been beyond

their power for years, namely, to indulge in alcohol

in moderation. Others, again, have imagined that

after leaving the sanatorium they would be unable to

take any kind of alcohol without immediate dis-

tressing symptoms, such as nausea and vomiting.

All these have been undeceived, with the result that

in some cases they have changed their minds as

regards undergoing treatment.

The assertion that the craving for alcohol can be

counted upon to remain in abeyance indefinitely

unless some alcohol has been taken does not of

course apply to the small class of true periodic

dipsomaniacs (p. 6t).

Undoubtedly the most important, as well as the

most difficult task devolving upon the superinten-

dent of a sanatorium for alcoholism, is to see to it

that the alcoholist is allowed no chance of escape

from the conclusion that total, and permanent total

NECESSITY OF PERMANENT ABSTINENCE igl

abstinence is absolutely essential in order to avoid

relapse. The superintendent himself may or maynot hold the view that total abstinence should

be the unvarying rule for the whole of the

human race ; but if he does it will be highly

inexpedient for him to impart this view into his

argument. Should he do so he will certainly weaken

his case : his patient will regard him as an extremist,

and consequently discount all he says. For he,

doubtless, has many acquaintances who have taken

alcohol in strict moderation for many years with no

perceptible harm, and certainly with no temptation

to exceed. Far safer will it be for the superinten-

dent to take the position that the patient is an

individual with one special weak point to which it

will always be necessary for him to live down. It

may even be admitted that he will lose some enjoy-

ment in life through his inability to take alcohol in

moderation, but it can be pointed out that there are

numerous compensations : he may be likened to an

enthusiastic tennis player, who, having become lame,

is obliged to forego tennis, but may yet make a big

success at croquet or billiards.

In endeavouring to persuade the patient of the

inevitability of the relapse into excess which follows

even slight indulgence, stress should be laid uponthe statistical argument. Thus Norman Kerr in his

very large experience knew of but two cases in which

the cured inebriate after a prolonged term of

abstinence became and remained a very moderate

drinker.* For myself, I am not sure that I know of

one such case. It is true that in the statistical

* ' Inebriety or Narcomania,' 1894, p. 400.

192 ON ALCOHOLISM

statement of results (p. 253) cases are set down as

improved but not abstainers. But the last informa-

tion concerning most of these cases is not very

recent ; none of them can yet be regarded as

permanent ; and the exact meaning of the term" improved " is not stated. The most striking testi-

mony, however, to the inevitability of the relapse

which follows the consumption of alcohol is the

statement of Dr. Branthwaite, inspector under the

Inebriates Acts, that " after thirty years experience

of inebriates, embracing a knowledge of some10,000 cases (he) does not know a single instance

where a typical inebriate, who has become sober,

has remained sober as a moderate drinker."*

Stress must also be laid upon the full meaning of

total abstinence. Everything the patient takes,

whether liquid or solid, must be chemically free from

alcohol. Many so-called "temperance" and " non-

intoxicating " beverages, even some described as

" non-alcoholic," do contain an appreciable amount

of alcohol. The term " non-alcoholic " would seem

to be used sometimes to imply free from added

alcohol. But, as is well known, all fermented

beverages necessarily contain alcohol, although the

percentage may be low. And all such must be

avoided by the ex-alcoholist. For observation shows

that in some patients the constant ingestion of

fluids containing even low percentages of alcohol is

capable of keeping alive, or even re-creating, the

alcoholic craving. A patient, who was intensely

anxious to remain well, limited himself to ginger-ale

of a well-known and deservedly popular brand : it

* ' Brit. Med. Journ.,' September 2nd, 191 1, p. 518.

DANGER OF FERMENTED BEVERAGES I93

was fermented, but contained no added alcohol.

Shortly, however, he seemed to become dependent

on it ; and in the course of a few months was taking

more than a dozen bottles a day: this, although

he was ignorant of the fact that it contained alcohol.

Eventually he reached the limit of his capacity for

fluid, and yet remained unsatiated, whereupon he

fell back upon whiskey and soda. I honestly believe

he would have remained well had he restricted

himself to non-fermented beverages. It should be

pointed out that even were it possible to take alcohol

and refrain from excess, the ex-alcoholist so acting

would be much worse off than the abstainer. For

he would be one of those who remained sober

through constant exercise of will, and whose mental

condition is incomparably less comfortable than that

of those who remain sober through absence of

temptation (see pp. 7, 8).

In spite—perhaps in consequence*—of the fre-

quent change in the personnel of the patients there

is very real esprit de corps in the sanatorium, the

which is shown in many ways. Those who have" turned the corner " and " are feeling fit " in spite

of abstinence are always ready to sympathise with,

and cheer up, the new-comer, who, not having even

arrived at the " corner," is irritable and despondent.

It is a never-ceasing source of wonder to note howtactfully kind and considerate to one another are

patients suffering from alcoholism—a class, it may

* There is a tendency, when people are long and exclusively asso-

ciated together, for them to become mentally stale, bored, and irrit-

able. This is often noticed in long voyages in sailing ships, where

there are few or no passengers.

13

194 0N ALCOHOLISM

be remarked, which is often charged with consistent

untruthfulness and loss of all moral sense.

It has been said that the association of manypatients suffering from alcoholism and inebriety has

a bad influence. This may be—and probably is

—true of retreats where patients are detained

involuntarily and for long periods. But it certainly

is untrue of a free sanatorium. Here the association

of many patients is not only not injurious, it is dis-

tinctly beneficial : it is beneficial in many ways. For

it can be shown that patients obtain the full benefit

of both good examples and bad examples, without

the drawbacks attaching to either. The influence of

good examples may be illustrated by the following

case :

A clergyman of the Church of England had resided for

some weeks with a medical man—he was the only resident

patient. Though put through practically the same medi-

cinal treatment as is used in the sanatorium, he failed to

break himself from taking alcohol—he never, indeed,

obtained a clear start. Then he entered the sanatorium

and quickly recovered. I may say he was deeply grateful

to the medical man with whom he stayed, and who treated

him with extreme kindness and attention. To me he

explained both his failure and success in these words

:

" There I was praying alone : here I have been praying in

church amidst a sympathetic congregation."

It must not be inferred that the social atmosphere

of the sanatorium at all resembles that of the inner

precincts of a cathedral city : that would be a serious

error. The reverend patient simply meant that an

effort to attain a given object is easier, and more

likely to be rewarded by success, when made in con-

INFLUENCE OF EXAMPLES I95

junction with others sinGerely striving towards the

same end. His analogy was, I think, unquestionably

true, though it must not be forgotten that in any case

loneliness and boredom are serious obstacles, social

surroundings and interesting occupations of great

assistance.

The influence of a bad example is, if anything, moreefficacious than that of a good example. By turning to

the chapter on results it will be seen that something

under 50 per cent, of the patients treated are knownsooner or later to relapse. Now a high percentage

of these come back for a second course of treatment

;

and quite a number of such returned cases remain

well subsequently. Hence it happens that during

the six or eight weeks' course of treatment of any

one patient, there are always some relapsed patients

admitted. These relapsed patients are in a way a

class by themselves : they are regarded by the others

as specially experienced in sanatorium methods and

results. And it is natural for patients undergoing

treatment for the first time to consult such " old

hands " as to their experiences. Now, what the newpatient learns from the old is, I have reason to know,

of special value—often of greater value than the

advice he obtains from the superintendent. Most

important of all, the new patient begins to believe

what he has hitherto been only told, although he

probably even now does not fully realise the truth and

significance of the fact, that a single alcoholic drink

of any kind will inevitably involve relapse into his

previous condition. For all these relapsed patients

(omitting the rare cases of true dipsomania) will

assure him that, after leaving the sanatorium, they

196 ON ALCOHOLISM

were never annoyed by any craving for alcohol until

after they had taken some : that the first drink,

whether taken through carelessness, forgetfulness,

or otherwise, was not taken in response to any craving,

but that craving rapidly followed the taking of the

first drink. It seems a little curious that the state-

ment of a patient, who has hitherto been more or

less of a failure, should have a greater convincing

value than that of a physician with special experience

of alcoholism ; but so it undoubtedly is in manyinstances.

In other ways the admission of patients, whether

old or new, who are obviously alcoholised, if not

intoxicated, is apt to operate beneficially on the

residents. Very often, when everything in the

sanatorium has been for a time proceeding smoothly

—perhaps too smoothly—one may notice a tendency

to general slackness, a tendency to treat the whole

subject of alcoholism with insufficient seriousness, if

not levity. It is at such times that the patients will

be found missing occasional doses of medicine, being

a little late for meals, etc. ; and it is at this stage

that the humorous side of alcoholism, never allowed

to sink entirely into oblivion, is apt to assert itself in

the smoking room. Then suddenly a new arrival,

not sufficiently intoxicated to be sent to his room,

joins the small community and attempts to make

himself generally agreeable. The impression he

makes is excellent, though hardly what he intends.

Perhaps never before have those who have now" turned the corner " realised how deadly un-

interesting is the conversation of the semi-intoxicated

individual, what a terrible bore he can be, and what

INFLUENCE OF BAD EXAMPLES IQ7

an ass he commonly makes of himself. Alwaysbefore, when associating with a person in such a

state, they have themselves been more or less

attuned. Now, however, they see him from the real

outsiders' point of view—from the standpoint they

themselves have so often been seen—and this gives

them much food for serious thought. At any rate,

all slackness in the sanatorium suddenly ceases, and

drink yarns go quite out of fashion for the time

being.

The kindness and consideration shown to each

other by the patients is never more noticeable than in

the case of the very few patients who are socially

somewhat below the average. Occasionally I have

felt a little doubtful as to the expediency of accepting

such a patient : I have questioned whether it was

fair to the others. But I can conscientiously state

that never yet (except in one solitary instance) have I

had reason to regret doing so. The alcoholist

—

most certainly the male alcoholist—is very rarely a

snob. Possibly, through an abiding consciousness

of his own weaknesses, one of his most distinguishing

traits is tolerance—a very broad tolerance indeed.

And so it happens that the socially inferior patient

is commonly made more of than any other, and has

not infrequently ended by becoming the most popular

member of the community.

The facility with which patients are weaned from

alcohol, and the freedom from the insistent desire

for alcohol which soon ensues, are undoubtedly due,

in part, to the efficiency of the regular course of

medicinal treatment which is pursued in the majority

of cases. But the ultimate results—the duration of

igS ON ALCOHOLISM

the period of abstinence which follows—depend

upon a multiplicity of factors. It goes without

saying that much depends upon the personality of

the patient and upon his subsequent environment

;

but much depends also upon the appeal which is

made to him during his stay in the sanatorium.

Having regard to inebriety generally, such appeals

are, of course, extremely varied in accordance with

the wide diversity in the temperaments of patients ;

they vary also of necessity with the personality of

the physician. But speaking only for myself andchiefly of the chronic alcoholist, the most generally

efficient is the appeal to the patient's common-sense.

For the chronic alcoholist—more particularly, of

course, the chronic sober alcoholist—is probably

more often than any other class of alcoholist a

shrewd, hard-headed man of business : tempera-

mentally he is the least neurotic of alcoholists ; and

he is consequently more open to persuasion through

his reasoning faculties than his emotions. Heshould therefore be taken fully into the confidence

of the physician. It should be pointed out that the

acquired capacity for ingesting large quantities of

alcohol without showing signs of intoxication of

necessity carries with it the more than compensating

incapacity to remain even temporarily on a normal

level of comfort and wellbeing in the absence of

alcohol—in short, that tolerance of, connotes con-

tinual slavery to, alcohol. The chronic alcoholist

may well be encouraged to take an intelligent

interest in the pathological tissue changes to which

he, more than alcoholists generally, is subject. Onetelling demonstration can nearly always be made.

AVOIDANCE OF WORRY I99

The most constant evidence of tissue damage is in

the kidneys : with rare exceptions chronic alco-

holists have albuminuria while they are drinking

and for a time thereafter; and it is decidedly im-

pressive to take patients daily into the laboratory

and show them the steady fall in the amount of

albumen passed during successive days of abstinence.

Worry, more than any other single cause, operates

to defeat the objects of treatment. This is equally

true whether the patient be suffering from alcoholism,

morphinism, or other drug habit.

Consequently every endeavour is made to shield

the patient from worry of all kinds during his course

of treatment, especially during the tapering stage.

With this object, the following italicised paragraph

has been inserted in the prospectus of the sana-

torium :

" It is earnestly requested that relatives and friends will

refrain from inditing correspondence likely to cause worry,

business or domestic, to the patient."

It might be thought that relatives or friends whohad for many months, perhaps years, endeavoured in

vain to persuade the patient to enter an institution,

would have been only too anxious to lend their full

assistance in the management, or at least to avoid

errors of commission calculated to neutralise the

effects of the treatment. Yet experience shows that

such is by no means always the case. Too often it

would seem they allow their feeling of resentfulness

to over-ride their reason. Recognising that all their

well-meant advice in the past had been wasted

through the lack of receptivity of the more or less

200 ON ALCOHOLISM

narcotised patient, they seize on the period of treat-

ment in the sanatorium as the golden opportunity

for impressing upon him the misery and disasters he

has brought upon his family. Shortly after his

admission, when perhaps he is suffering somewhatacutely from the want of his accustomed narcotic andfrom remorse generally, I have seen the patient

flooded with correspondence full of bitter upbraiding

or cheap and entirely futile advice. It can safely be

asserted that in no single instance has this practice

done any good, whereas in some it has rendered

abortive all the efforts of those in charge of the

patient ; in any case, it never fails to make the

management of the case more difficult than it need

be. During the early days of treatment in the sana-

torium, no effort should be spared to save the patient

from worry of all kinds. With each succeeding weekhe becomes increasingly able to appreciate well-

meant advice and to forgive tactlessness for the sake

of sincerity. And it is towards the end of, if at all,

during his period of treatment, that he will be found

responsive to reason and fitted to face the problems

of his future.

There is a point of policy which may perhaps be

referred to most appropriately in this connection.

Though quite illogical, there exists a wide-spread

idea that residence in a sanatorium for alcoholism,

whether free or other, leaves behind it something of

a stigma. Many patients, therefore, wish to avoid

recognition while in residence ; nor are they anxious

for publicity subsequently. Hence it is a common,

and in my view, an eminently justifiable plan to

enter under an assumed name. The plan is especially

CHANGE OF SURNAME 201

expedient in the case of professional men, such as

lawyers, medical men, and clergymen, in whom loss

of income or position might easily follow detection-

It is expedient also in the case of titled persons,

whose identity is so easily established.

Medical men commonly enter with the idea of

concealing their profession. But experience showsthe attempt to be always futile. Invariably within

a few days their occupation is known to all : bysome chance scientific expression they have "given

themselves away." I have been in the habit, there-

fore, of advising medical men frankly to admit their

profession, but to change their surname to somemoderately common name of the same initial letter.

So they are relieved from the necessity of constantly

acting a part—in itself a great advantage. Andeven if in the end, through some slip on their part,

their real name comes out, that is of compara-tively little importance. The custom of name-changing is well recognised in the sanatorium, and

any acquaintances they have made therein well

remember them (if at all) under the pseudonym.

Diet.

Various systems of diet have been claimed as cures

for alcoholism. The system most persistently advo-

cated is vegetarianism or that modified form of

vegetarianism which permits milk and cheese,

perhaps eggs. It is said that the stimulation caused

by meat extracts (and other uric-acid forming

materials) is followed by a reactionary depression

which in turn demands stimulation by alcohol. (In

passing it may be mentioned that some of those who

202 ON ALCOHOLISM

thus argue maintain elsewhere that alcohol has nostimulant properties, but is merely a narcotic.) In

any case the question can be decided only by

experience, and Norman Kerr, who himself confesses

to a partiality to the vegetarian idea, was driven to

acknowledge eventually that the claims of vegetaria-

nism with regard to alcoholism were baseless.* Hepoints out the constant association of whiskey and

porridge in Scotland, and that of enforced vegetaria-

nism and extreme drunkenness in some oriental

nations. The South Sea Islanders at home pro-

bably eat less animal food than any other race, yet

their craving for alcohol when accessible is usually

uncontrollable. There seems a somewhat obvious

fallacy underlying the claims of the various diet

cures. The alcoholist who lives on an ordinary

mixed diet naturally finds any special system un-

pleasing. Yet when strongly recommended by a

physician in whom he has confidence, he may be

ready to abide by it. And the patient who follows

most strictly his physician's advice is the good

patient, and, other things equal, the patient most

likely to remain an abstainer. On the other hand,

the patient who disregards the physician's advice in

one thing, say diet, is he who is likely to disregard

it in others and so relapse. It is then easy to explain

the relapse by laxity of diet.

Nevertheless, I am myself inclined to believed

that a diet which is largely, but by no means exclu-

sively, vegetarian has a place in the treatment of

alcoholism. And certainly a diet consisting mainly

of lean meat is injurious in so far as concerns the alco-

* 'Inebriety or Narcomania,' 1894, p. 320.

DIET IN TREATMENT 203

holic habit itself. Unless specially contra-indicated by

complications, there should always be at every meal

a fairly generous allowance of carbohydrates, perhaps

especially sweet carbohydrates. This conclusion has

been arrived at through observation.

With most alcoholists there are certain periods in

the day when the craving is at its worst, when con-

sequently the patient is accustomed to drink most

freely, and when after withdrawal he is most likely

to relapse. In the sanatorium breakfast is at

8.30 a.m., luncheon at 1 p.m., afternoon tea at

4 p.m., and dinner at 7 p.m. And assuming he has

slept well through the night, the ordinary patient

will begin to crave for alcohol most insistently an

hour or more before luncheon and dinner, that is,

about 11.30 a.m. and 5.30 p.m., and this will con-

tinue until the evening meal. The early morning

craving, of course, is common, but chiefly at the

commencement of treatment ; also it is usually the

first to cease. The craving is referred to the epigas-

trium, and is described as a sensation of " sinking"

or " emptiness." It seems to be connected with the

end of gastric digestion, for it is contemporaneous

therewith and ceases after meals. Moreover, it can

be relieved at any time by a little food, preferably a

glass of hot milk, to which has been added a teaspoon-

ful of powdered ginger, or a drop or two of any fluid

preparation of capsicum. Now a lean meat meal

undergoes rapid digestion in the stomach, which is

left empty long before the succeeding meal is due,

and in these circumstances the craving for alcohol

returns simultaneously. But by an adequate admixture

of starch foods, potatoes, puddings, etc., the process

204 ON ALCOHOLISM

of gastric digestion is considerably prolonged, and by

so much the dangerous period postponed, if not

altogether evaded. It is for this reason that after-

noon tea, together with some solid food, is insisted

on. And patients who are spending the time between

luncheon and dinner away from the sanatorium are

always instructed not to miss this small meal, which,

if possible, should be taken at or near the usual hour.

Sugars and sweet things generally have a special

inverse relation to alcoholism. It is well knownthat chronic alcoholism kills the desire for sweets,

the taste for which, however, nearly always returns

—even after remaining for years in abeyance—within

two or three weeks from the final withdrawal of

alcohol. Hence obvious enjoyment of the sweet

course is accepted in the sanatorium as a satisfactory

index of recovery. But the inverse relation does not

end here. There is a converse. It is certain in

some cases that the ingestion of sweets of any kind

is capable of controlling for a time, at least, the

craving for alcohol. One patient, a mild but true

dipsomaniac, whose outbreaks occurred at irregular

intervals and quite without warning, had discovered

this fact for himself. When walking along the

street he would suddenly be attacked with a craving

for spirits, and would make his way without further

thought to the nearest hotel. Sometimes, however,

he would pass a confectioner's on the way, and if he

could make up his mind to enter and eat some

chocolate creams or other sweetmeat, all desire for

alcohol would immediately leave him. The occur-

rence or otherwise of a dipsomaniac paroxysm would

thus sometimes depend upon whether he first came

TOBACCO 205

across an hotel or a confectioner's. But I am afraid

it must be admitted that most often he first happened

on the hotel, perhaps on account of its greater

conspicuousness.

Tobacco.

The relations between smoking and alcoholism

remain unsettled. For my own part I am unable to

see any real connection between the two drug habits.

Certainly most male alcoholists smoke ; but in somethe two habits alternate rather than concur: smoking

is indulged in mainly, if not solely, during the

intervals of abstinence from alcohol. Norman Kerr,

who proclaims himself no defender of tobacco, which

he regards as a pure luxury, injurious to the health

of many even when used in moderation, is driven to

conclude that there is no true tobacco inebriety or

mania.* Further, he has little doubt that the con-

tention that the tobacco habit conduces to alcoholic

inebriety is in general untenable.t He regards the

frequent association of the two habits as accidental,!

and he mentions some instances in which the seda-

tive influence of tobacco successfully subdued the

alcoholic craving for the time being.

§

At the present time the hostility of a large section

of extremely well-meaning temperance philanthro-

pists is directed mainly against the cigarette habit.

It has even been said in public by a well-known

temperance protagonist that he would sooner see his

son an alcoholic inebriate than a confirmed cigarette

smoker. All such over-statements may be allowed

* ' Inebriety or Narcomania,' 1894, p. 148.

t Ibid., p. 207. J Ibid., p. 208. § Ibid., pp. 209,378.

206 ON ALCOHOLISM

to pass. And we may still proceed to weigh the

evidence.

As regards the toxicity of tobacco, there can be no

doubt that, other things being equal, cigarettes

represent the minimum. Some few years ago the' Lancet ' stated that hitherto the only form of the

tobacco habit which had not caused tobacco ambly-

opia was cigarette smoking. Chewing strong tobacco

is probably the most toxic form, after which comes pipe

smoking of strong tobacco, and strong cigars. Thewriter is himself a cigarette smoker for the reason that

pipe smoking still exerts toxic effects, such as cold

skin, and a tendency to nausea : he has for someyears lost his full tolerance of tobacco taken in this

form. And in a few patients who were obviously

suffering from tobacco toxaemia, the symptoms have

been promptly relieved by substituting cigarettes for

the pipe. Pipe smokers dislike new pipes as a rule,

and it may be supposed that a pipe becomes increas-

ingly toxic with continued use.

It must be admitted, however, that there is one

great disadvantage connected with cigarettes. They

conduce to excess, and this in many ways. They are

convenient to carry, they do not scent one's clothes

because they are always thrown away when once

lighted ; and unlike pipes and cigars, they can be

smoked on almost every conceivable occasion, even

in many drawing rooms. Nor are they any trouble.

Consequently the cigarette smoker finds himself

lighting cigarette after cigarette in mere absence of

mind, often when he really does not care whether he

smokes or not. There is an obvious remedy for this

tendency. Let the cigarette smoker learn to roll his

CIGARETTE SMOKING 207

own cigarettes. Let him carry a pouch of good

cigarette tobacco and a book of papers. He will

then know what kind and quality of tobacco he is

smoking, and he will be automatically precluded

from smoking when he is really indifferent to it.

This plan has been recommended on many occasions,

and as a rule, the immediate result has been a

reduction in the daily number of cigarettes of about

two thirds, and that without any inconvenience or

discomfort. The smoker will not go to the trouble

of rolling a cigarette unless he really feels inclined

for a smoke. So much for mere excess.

As regards the widely spread view that cigarette

smoking conduces to the alcoholic habit, there is a

series of facts which seem to me conclusively contra-

dictory. All middle-aged persons can readily call to

mind the time when cigarettes were almost unknownin this country : cigarette smoking in the street

proclaimed the foreigner or one who had resided

abroad. Since then the habit has become ubiquitous.

Yet will anyone assert that alcoholism has increased

meanwhile ? Again, take those countries where

cigarettes have been in common use for much longer

than in the United Kingdom. In Spain, Portugal,

Sicily, Southern Italy, Greece, Turkey, on the north

coast of the Mediterranean, and in all the provinces

on the northern seaboard of Africa, cigarette smoking

is comparatively an old institution. Yet all these

are sober countries—therein is no temperance

question.

CHAPTER VIII

Treatment {continued)—The withdrawal of alcohol ; cases suited for

sudden withdrawal; cases suited for tapering; principles of

successful tapering—Special drugs used; apo-morphine hydro-

chloride; bromide of sodium ; special hypnotics ; strychnine,

atropine, cinchona rubra, and gentian ; morphine tartrate

;

rationale of the action of drugs used in alcoholism—Duration of

treatment; after-treatment; parting advice.

The Withdrawal of Alcohol.

The inadvisability of insisting on the sudden with-

drawal of alcohol in all cases has been dwelt upon

(p. 115). Even in patients admitted into licensed

retreats under the Inebriates Acts, it is found ex-

pedient occasionally to allow a little alcohol as a

placebo for a day or so after admission. And it is easy

to see that in a voluntary sanatorium, where patients

may leave at any time without notice, the pressure

of expediency is felt more frequently and more

insistently. In this chapter, however, I am con-

sidering cases in which alcohol should be at once

withheld, or, on the other hand, cautiously tapered

off, from the sole standpoint of the patient's recovery

without unnecessary suffering and without avoidable

complications.

As a general rule, the question of tapering versus

sudden withdrawal must be decided by the existence

SUDDEN WITHDRAWAL 200,

or absence of acquired tolerance to alcohol. In most

cases of dipsomania and pseudo-dipsomania the

patient has been drinking for a few days only, and nodegree of tolerance worth considering has been set up.

In such it is important to avoid even a single dose

of alcohol. Alcohol here gives only momentaryrelief: indeed, in most cases it is patent that a

marked increase in the dipsomaniac craving follows

very shortly after each dose. The history of manyof these patients who have been treated during the

outbursts in their own homes, by their own medical

attendants, shows clearly that by giving alcohol in

moderate doses—doses insufficient to cause gastric

catarrh or other kinds of physical illness—the dipso-

maniac or pseudo-dipsomaniac paroxysm may be

prolonged almost indefinitely. When this line of

treatment is pursued—and it is often the only line

which is possible in private practice—one of two

events nearly always happens : (i) The patient is

persuaded or morally forced to enter some institu-

tion like the Norwood Sanatorium ; or (2) he takes

matters into his own hands, drinks alcohol of some

sort in enormous amounts, and quickly brings on

physical prostration of some kind, and with it the

end of the paroxysm.

Cases suited for sudden withdrawal.—Reference has

been made to differences in the character of the

dipsomaniac and the alcoholic cravings respectively

(p. 89). These differences have an important

bearing upon therapeutics. As will have been

already gathered, the administration of alcohol in

the dipsomaniac craving is not merely futile— it is

positively harmful, in that it inevitably prolongs the

14

210 ON ALCOHOLISM

condition of mental unrest. Alcohol, therefore,

should be at once withheld, and nothing short of the

certainty of driving the patient to leave the sana-

torium allowed to interfere with this practice. Thedipsomaniac craving can, and should, be imme-diately quenched by apomorphine, as will be pointed

out presently.

There are a few exceptions to the rule that alcohol

should be suddenly withheld in pseudo-dipsomania.

As stated previously (p. 86), there are cases classed

as pseudo-dipsomania, which approximate to chronic

inebriety or even to chronic sober alcoholism. In

such the paroxysms are comparatively mild and

proportionately prolonged, and consequently there

may be established a certain degree of tolerance.

If so, it is advisable to taper, but the tapering rarely

requires to be extended beyond two or three days.

Cases suited for tapering.—In chronic alcoholism,

whether inebriate or sober—but much more parti-

cularly in chronic sober alcoholism—tapering is

usually advisable, often essential, and never injurious.

This does not mean that all chronic alcoholists whoenter the sanatorium are tapered. Some, impressed

by the common belief that medical men always

insist upon sudden withdrawal, and dreading the

effect thereof, have tapered themselves off during

the week or so before entering. Others have been

tapered off by their own medical attendants as a

preparation for entry. And a few—a very few

—

have themselves insisted upon sudden withdrawal

after entry. The last have made a definite resolu-

tion not to touch alcohol of any sort after crossing

the threshold of the sanatorium ; and it has been

CASES SUITED FOR TAPERING 211

usually considered best not to interfere, although,

as a matter of fact, an attack of delirium tremens

has resulted in more than one of these cases.

The special necessity for tapering in cases of

chronic sober alcoholism is seen in the previous

histories as regards drunkenness of twenty-eight

cases of delirium tremens, referred to on p. 152.

It is not always possible to estimate accurately the

degree of tolerance set up. Many patients are

honestly ignorant of the amount of liquor they have

been accustomed to take. And others, through a

sense of shame, deliberately practise concealment.

The latter are not uncommon : they may be a source

of danger to themselves ; and they are responsible

for the prevalent view that delirium tremens mayarise in the moderate drinker, and, indeed, even in the

abstainer. Hence after admission, it is frequently

advisable to institute a short tentative period of

abstinence, watching the patient carefully the while.

In those who have acquired much tolerance, un-

mistakable symptoms soon make their appearance.

Most of these are well known. Such are nervousness

and restlessness, insomnia, muscular tremor, and

anorexia, with vomiting or retching. It is important

that those should not be allowed to continue.

Especially is this true of the digestive symptoms.

Vomiting and retching are commonly attributed to

gastric catarrh, from the direct irritant action of

alcohol on the gastric mucosa, and no doubt often

correctly so. But it is not, I think, widely recog-

nised that these symptoms may (and very often do)

arise directly from the sudden or too rapid withdrawal

of alcohol. Many chronic alcoholists are quite unable

212 ON ALCOHOLISM

to face food (even the sight or smell of it sometimes)

during a short period of abstinence. In them,

alcohol given on a quite empty stomach restores for

the time being, not only the appetite, but the powerof digestion. On the other hand, if the complete

abstinence from alcohol is prolonged, the anorexia

not infrequently passes into constant retching andtotal inability to retain anything on the stomach,

even alcohol given in its most tempting form, for

instance, iced champagne. Then the possibility of

satisfactory "tapering " is practically lost. This is the

immediately antecedent history of many an attack

of delirium tremens and alcoholic epilepsy. It is

important, therefore, to prevent the onset of the

gastric revolt, and this can practically always be done

by giving alcohol in appropriate doses. The onset

of many of the symptoms above referred to, extreme

restlessness, muscular tremor, etc., should be accepted

as an indication for tapering. And the same is true,

as already mentioned, of the existence of marked

albuminuria.

The principles of successful tapering.—When tapering

is carried out with perfect success there are not only

no complications, but no symptoms—that is to say,

no additional symptoms—nor indeed, any added

suffering or even discomfort. It is, therefore,

necessary to formulate certain general rules for

tapering. With this aim in view I have made a

series of tapering charts, and selecting only those in

which the withdrawal of alcohol was unaccompanied

by symptoms, have combined these into a single

composite chart. This chart, which explains itself,

is represented below.

PRINCIPLES OF TAPERING 213

In the case represented there is supposed to be a

tolerance of whiskey of about one bottle (26 fluid

ounces) a day ; that is to say, the patient has for a

considerable time taken approximately that amountof spirits without obvious symptoms other than

odour of breath. He may, or may not, have been

Chart 2 (alcowoltaperino)

20

1

15

10

- "^—

>.*6

^— >J>

-\

_s^0

->6

-

- \«\ii

sc3og3C

12 3 * J 6 T

Vevys following admission-

intoxicated at times, but only when the amount

stated was exceeded, or taken with unusual rapidity.

It will be observed that the curve formed is prac-

tically a straight line. There must be no sudden

fall in the amount given ; and this is especially

important during the first two or three days. On the

other hand, after the fourth or fifth day, when the

amount of alcohol has fallen to four or six ounces,

further tapering is often unnecessary : indeed, some

patients at this stage themselves suggest complete

214 ON ALCOHOLISM

and final withdrawal. The tapering curve then

becomes convex with the convexity upwards.

Undoubtedly the most important point from the

standpoint of avoiding symptoms and complications

is the cautious reduction from the amount of acquired

tolerance during the first three or four days. Failure

to recognise this is accountable for many cases of

delirium tremens. From such cases it is apt to be

argued that tapering does not prevent the occurrence

of this complication. I think I am correct in saying

that in private practice and general hospitals during

recent years it is rare for a patient, even one who is

obviously a chronic alcoholist, to be ordered morethan eight fluid ounces of spirit during the twenty-

four hours. At any rate, this is true of those general

hospitals with which I have been connected for

many years. Yet, in those who have acquired high

tolerance, this amount of alcohol may be quite inade-

quate to prevent complications, especially, perhaps,

in severe traumatism and acute pneumonia. Asalready asked, what is the value of eight fluid ounces

of whiskey to a patient who has for many weeks or

months regularly absorbed into his system twenty-six

to forty fluid ounces with but slight signs of intoxi-

cation ? The subject is of more vital importance in

general hospitals than in a sanatorium for alcoholism.

In the latter, delirium tremens is rarely complicated:

it is very unlikely to be fatal ; and convalescence,

especially from a first attack, is almost always

followed by a prolonged period of abstinence from

alcohol. On the other hand, in severe compoundfractures or acute febrile diseases, it is obvious there

can be no more unfortunate complication than an

ALCOHOL AND MORPHINE TAPERING 215

attack of delirium tremens : even when the patient

survives, its onset may easily turn the scale in favour

of amputation as against conservative surgery. Witha view to its prevention, it should not be lost sight

of for a moment that in those who have established

tolerance, a certain amount of alcohol—often a very

large amount, when measured by ordinary standards

—has, for the time being, become an essential of" normal" existence, and it need not be argued that

mid-stream is an unwise place in which to change

horses. As was to be expected, acquired tolerance

of alcohol presents many features in common with

acquired tolerance of morphine. In both tolerance

is established by means of small, regular, but ever-

increasing doses. In both the euphoria which at

first followed each individual dose, and which led to

the formation of the habit, soon ceases: the con-

tinuance of the drug is then necessitated by the

misery caused by its omission. And in both the

degree of tolerance is a very accurate measure of

the intolerance of its sudden withdrawal.

But when we come to treatment, there is at least

one important point of contrast. The tapering

curves differ essentially. In morphinism it is almost

always easy to commence with a sudden large reduc-

tion in the daily allowance : as a general rule, the

dose may be nearly halved at once, without causing

more than discomfort. Such a reduction, as above

pointed out, may lead to complications in alcoholism.

On the other hand, while the smaller amounts are

easily got rid of in alcoholism, the reverse is the case

in morphinism. In morphinism, as is well known,

there is often more difficulty in getting rid of the

2l6 ON ALCOHOLISM

last grain than in, say, the first 19 gr. These

differences in the two drug habits are an interesting

subject for speculation : at present, however, they

are matters for observation, not explanation.

The following is a composite chart, constructed

from a series of charts of morphine cases treated bytapering, without complications, and with compara-

tively little suffering.

It will be observed that the curve has its concavity

upwards. The first reduction in dose is always the

chAi-t 3 (Aorphinc tapering;

to -

\

-

5L. -

S : \O

C _

\

O _

O12 5 16 o 7 a O lo U IS 15 l-» IJ Id 17 19 13 *o

• DAya follo»?Jr\<$" Admission

largest that can be made without causing suffering.

Thenceforward the daily reductions become smaller

;

while towards the end of the tapering process, the

most insignificant reductions may become matters of

real moment to the patient. It is not rare at this

time to find that the administration of ^ or even

^. gr. renders the patient quite happy for some

hours.

Comparing the two charts (alcohol and morphine),

* This chart somewhat understates the average time required in

the withdrawal of morphine.

SPECIAL DRUGS USED IN ALCOHOLISM 217

one may say roughly that the curves represent an

arithmetical and geometrical progression respectively.

The rapidity with which alcohol may be tapered

off varies with the amount taken, but especially with

the length of time during which it has been unin-

terruptedly taken, and the consequent degree of

tolerance established. In no case is it necessary,

however, to spend more than eight or nine days over

the process ; and there are very few in which six or

seven days are not ample. But often it happens that

a patient has not so much time to spare : he has

important appointments which cannot be deferred.

Then it is necessary to taper rapidly and conduct

him to the " corner " in the three or four days. In

such cases a certain amount of risk—not much—must

be incurred, which is no doubt greatly minimised by

appropriate hypnotics. But the most important

point in rapid tapering is the avoidance of all physical

exertion, to ensure which end the patient should be

kept absolutely in bed for several days : even the

muscular effort of dressing must be avoided. Alcohol

is eliminated mainly by combustion, and the rate of

combustion (estimated by the output of carbonic

acid) during hard muscular exercise and complete

physical rest respectively is as 3, 4, or 5 to 1. Andclinically the physiological influence of a dose of

alcohol is proportionately enduring when the body is

at complete rest. The same is true of morphine.

Special Drugs, other than Alcohol, used in

the Treatment of Alcoholism.

These are apomorphine hydrochloride, bromide of

sodium, various hypnotics (e. g. veronal, trional,

2l8 ON ALCOHOLISM

sulphonal, paraldehyde, chloral hydrate, and hyoscine

hydrobromide) : strychnine nitrate, atrophine sul-

phate, red cinchona bark, and gentian ; and, very

rarely, morphine tartrate.

Apomorphine hydrochloride.—This drug is always

used hypodermically, and the most convenient

solution has been found to be i to 200. Apomor-phine is probably the most useful single drug in the

therapeutics of inebriety : no other acts so promptly

and certainly, and is so free from counter-balancing

disadvantages. In the sanatorium it is used in three

different sets of circumstances : (1) in maniacal or

hysterical drunkenness : (2) during the paroxysm of

dipsomania, in order to still the insistent craving for

alcohol ; and (3) in essential insomnia of a special

variety.

In maniacal or hysterical drunkenness, also termed

mania a potu, the effect of a full dose of twenty

minims of the solution given hypodermically is

startling: there is probably nothing in the whole

practice of therapeutics quite so striking. Just

previously the patient may have been shouting for

alcohol and wildly uproarious, necessitating restraint

by two or more attendants. Within ten or fifteen

minutes, usually much less, he is quietly asleep.

Given in this full dose the drug is always strongly

emetic, but the vomiting quickly ceases. The emetic

action is, of course, incidentally advantageous in the

circumstances. The hypnotic action is no less

certain and hardly less rapid than the emesis. In-

deed, in some cases, the patient is fast asleep before

the intermittent spasms of the diaphragm haveceased : hence there is a possible danger of asphyxia

APOMORPHINE IN MANIA A POTU 2IO,

if the patient is left too soon. The further course of

the case varies little. Practically always the sleep

induced lasts two or three hours : it is light, however,

for the patient is easily roused. In some cases he

remains asleep for seven or eight hours. When he

awakes his mental condition is entirely altered. Hemay be sober and rational. If not, he is at least

quiet and easily managed.

Although there is no fatality recorded from the

use of the drug, it is stated that apomorphine given

in full emetic dose (*'. e. -£$ gr. or 20 ni of the 1 to 200

solution) has occasionally been followed by severe

collapse. In the sanatorium, however, no symptomshave ever occurred which gave rise to the least

anxiety, except perhaps in the following case

:

An athletic gentleman, aged 34 years, was brought in in

an advanced stage of intoxication, and after being put to

bed with much difficulty, was given 15 TTL of the apo-

morphine solution hypodermically. He vomited several

times, and promptly went into a sound sleep. During the

succeeding hour his pulse fell steadily in frequency until it

numbered only 36 beats to the minute ; but there was no

change in his appearance, or any other symptom which

caused uneasiness : his pulse was of good quality, and

quite regular. I then roused him, and immediately the

pulse-rate rose to 80 or more.

It may be well, therefore, to adminster the drug in

smaller doses, say, 10 or 12 m of the solution,

although I should myself never hesitate to use 15 ir(_

in a violent case. In my hands 10 th. has occasionally

failed to cause emesis, but never to cause sleep. It

has been stated that apomorphine fails of its emetic

effect in alcoholism. This presumably refers to the

220 ON ALCOHOLISM

deep coma caused by acute alcoholic poisoning

;

for in ordinary alcoholic conditions it is difficult to

avoid the production of emesis. Certainly 15 in. of

the solution is always efficient both as an emetic and

as an hypnotic.

During a paroxysm of dipsomania, even in the

absence of intoxication, apomorphine is of great

utility. In minute doses it is much more rapidly

efficient in stilling the dipsomaniac craving than

strychnine and atropine. Four or even 3 m. of the

solution usually checks for some hours the incessant

demands of the patient. Commonly the first effect

observable is a slight sensation as of the commence-ment of sea-sickness, accompanied by a little facial

pallor. Any feeling of nausea, however, is evanescent,

and is followed by an hour or so of sleep. This result

is almost unfailing. The first case in which

apomorphine was used for the dipsomaniac craving

is illustrative

:

A gentleman, aged 40 years, was brought to the sana-

torium in a state of very advanced intoxication. He slept

well throughout the night. In the morning he was quite

sober, but craving for alcohol, which craving continued all

day. Had he not been supplied with some whiskey he

would have bolted. In the evening he became moreinsistent, ringing his bell every ten minutes, and imploring

for whiskey. At 10 p.m. he told me that unless he were

liberally supplied with whiskey he would be tramping about

the house all night. I then gave him 6 TH. of the apo-

morphine solution hypodermically. In a few minutes hesuddenly became a little pale, and his manner entirely

altered. He said, "That seems to have made me a little

squeamish, but I am quite sure I am going to have a goodnight's sleep. You need not trouble about that whiskey."

APOMORPHINE IN DIPSOMANIA 221

I remained for half an hour talking to him on common-place subjects, then, as he was obviously drowsy, I said

" Good-night." I heard no more of him until the morning,

when his dipsomaniac paroxysm was over.

A single injection of apomorphine will not by any

means always terminate a dipsomaniac paroxysm in

which the patient has already commenced to drink.

When he awakes from the apomorphine sleep he

may still be demanding alcohol, though he is never

then so insistent as before. Accordingly it may be

necessary to repeat the dose, and even to continue to

give it twice or three times a day—occasionally even

more frequently—for a day or two. Such repeated

doses, however, do not require to be so large : 4 or

even 3 ii\ is usually sufficient.

In dipsomaniac attacks which are only impending,

the action of the drug is much more efficient and

lasting : often one non-emetic dose is enough to

avert the whole paroxysm. This was shown very

clearly in the case of a gentleman who remained for

three months in the sanatorium. The attacks

occurred with great regularity, at first every seven,

later every ten days, usually in the morning or early

forenoon. He would then say of himself that he was" seething with excitement." On each occasion he

was directed to lie down for an hour and have 5 tt\

of the apomorphine solution hypodermically. After

this he would usually doze for about ten minutes,

and the effect was always most marked when this

happened. When he arose he would be mentally

stable and apparently safe until the onset of the

succeeding attack, seven or ten days later, In this

case, the paroxysms, having been successfully aborted

222 ON ALCOHOLISM

for seven or eight weeks, ceased to recur; and

six months later the patient remained well. Un-fortunately so lasting a result is by no means the

rule in cases of true dipsomania.

In one form of insomnia, a minute dose of apo-

morphine—4 to 5 or perhaps 6 v\ of the solution

—is an ideal remedy if given under the right con-

ditions. The form of insomnia referred to is that

in which the patient is unable to go to sleep. Hemay have felt more or less drowsy all the evening,

and yet immediately he lies down he is wide awake,

and remains so for hours. On the other hand, when-ever with some assistance he can once go to sleep,

he remains asleep, and puts in an excellent night's

rest. Apomorphine seems to be just the assistance

required in such cases. The patient must not only

be in bed, he must be in the exact position in bed

in which he is accustomed to sleep. Then the

injection is given, and he must make no movementsubsequently. Otherwise he may miss his oppor-

tunity ; for the effect of the drug is evanescent.

Usually he is asleep within a quarter of an hour,

often much sooner. But should he still be awakein half an hour, the injection should, I think, beregarded as a failure. The apomorphine sleep does

not in my opinion last more than two or two and a

half hours, though the patient may remain asleep all

night. Consequently, the majority of the hoursduring which he has slept have been passed in natural

sleep. This doubtless accounts for the fact that

the patient on awaking in the morning is far fresher

than he would have been after sleep induced by anyother drug.

APOMORPHINE IN INSOMNIA 223

What has been described as " alcoholic insomnia "

(p. 119) is the insomnia which affects chronic alco-

holists while they are still drinking : the patient can

go to sleep by taking alcohol, but he soon wakes and

can return to sleep only by taking more alcohol. In

this form apomorphine alone .is useless, unless the

physician is prepared to repeat the injection once or

twice during the night. But when he is being

tapered the chronic alcoholist often develops the

other form of insomnia. In addition to being unable

to remain asleep, he may now find it impossible to

go to sleep in the first instance. Here apomorphine

is of use ; but to make it of much use it should be

combined with some other hypnotic of more enduring

action. Hyoscine may be given in the same injec-

tion ; or veronal, etc., given by the mouth at the

same time as the injection. In this latter case, the

veronal or other similar drug begins to act before the

apomorphine has ceased acting, and a very satis-

factory night's sleep is obtained. But there often

arises a practical difficulty in following this course

:

the apomorphine may cause emesis, and so lead to

the partial or complete loss of the more enduring

hypnotic. Undoubtedly a great desideratum is a

slowly acting hypnotic with an enduring influence,

which could be given hypodermically and so in com-

bination with apomorphine. Morphine is a bad

hypnotic, and is, moreover, objectionable in alco-

holism on many grounds.

In all cases of insomnia the advantages of quiet

cannot be over-estimated. And much of the success

met with in the sanatorium is certainly due to the

site and surroundings of the institution. The house

224 ON ALCOHOLISM

is in the centre of the grounds, and the grounds

occupy ten or eleven acres in the centre of a large

private park, through which there is no general

thoroughfare. Consequently there are no night

noises, such as motor horns and motor buses : the

worst night sound is that of a distant railway whistle.

Apomorphine has been recently recommended as

a hypnotic in delirium tremens. I cannot myself con-

firm its value in this complication. In the one or

two cases in which I have used it, it has proved of

little or no use. But the fact is that by the time the

hypnotic action of apomorphine had been fully recog-

nised, cases of delirium tremens had ceased to occur

in the sanatorium : the recognition of the causation

of the complication had resulted in effectual pro-

phylaxis.

Bromide of sodium.—In all cases, except those

who have ceased taking alcohol for a week or morebefore entering—cases, that is, which have already" turned the corner "—the bromides are useful.

They are especially indicated in patients who are

undergoing tapering. By counteracting the tendency

to exaggerated reflex activity, always present in these

circumstances, they enable this process to be accele-

rated ; and if taken systematically throughout the

day, go far towards ensuring a restful sleep at night.

Formerly the potassium salt was used in combina-

tion with ammonium carbonate, but in a few cases

signs of cardiac weakness followed the rather pro-

longed administration of large doses, the only doses

of any material value in alcoholism. Consequently

the sodium salt is now exclusively employed. It is

given according to the following prescription :

SODIUM BROMIDE AND HYPNOTICS 225

R Sodii bromid. • gr. lx

Choloformi• mj

Liq. capsici cone. (Fletcher) • mjAquae ad . • 3ss

To be given every eight, six, or even four hours in

water.

The addition of capsicum tends to afford someimmediate relief from the sensation of epigastric

" sinking " which is so often complained of andwhich in so many cases constitutes an essential item

in the alcoholic craving.

After a day or two the dose of the above mixture

is halved, and later reduced to a quarter ; but this is

continued until the patient is sleeping moderately

well throughout the night without the aid of alcohol

or any special hypnotic.

Patients intolerant of the bromides are rare : in

only a few has acne developed, and the eruption

has quickly subsided on the withdrawal of the

drug.

Special hypnotics.—In addition to apomorphine and

bromide of sodium (the latter hardly a hypnotic), the

list includes veronal, trional, sulphonal, paraldehyde,

chloral hydrate, and hyoscine hydrobromide. It is a

long one, and my clinical acumen is insufficient to

judge of the respective values of these drugs, and to

state definitely which is the best. Nor can I say

that this one is most efficient in this case, or in this

set of circumstances, that one in that case, or in that

set of circumstances. Nevertheless, there is a reason

for the length of the list. The above does not, how-

ever, refer to hyoscine, for which there are special

indications.

15

226 ON ALCOHOLISM

It may be stated as a general rule in alcoholism

that hypnotics, unless given in adequate doses, are

injurious. To insure sleep the largest dose compa-

tible with safety is indicated. Now idiosyncrasy plays

so dominant a part in the action of all these drugs

that in prescribing one for a new patient it is impos-

sible at once to hit on the largest safe dose. This

difficulty is usually obviated by giving him his

accustomed hypnotic drug ; for in many cases the

patient has had such prescribed for him by his ownmedical attendant, and he knows, not only the name,

but the dose of the hypnotic used.

Incidentally reference may be made to the inex-

pediency of allowing patients—more especially ine-

briate or alcoholic patients—to learn the names and

doses of hypnotic drugs. Practically all of these can,

and do, set up drug habits ; and all such drug habits

could have been prevented by concealment. It seems

to me that medical men, even those who do not

dispense, could easily prevent this dangerous know-

ledge. Nearly all hypnotic drugs are prepared in

tablet form, and such could be supplied by the

physician himself with but slight inconvenience.

Indirect suggestion is markedly valuable in manycases of insomnia; and a 5-gr. tablet, specially manu-factured to be indistinguishable in appearance from

one of veronal, etc., but consisting merely of sugar

of milk, has proved of great practical utility in the

sanatorium. It is sometimes used in conjunction with

the hypnotic tablets mentioned in order to maskdecreasing dosage : sometimes alone in patients of a

certain temperament. Many have slept excellently

every night for weeks together provided they took

STRYCHNINE AND ATROPINE 2.27

two of these tablets on going to bed, but suffered

promptly from insomnia whenever their " sleeping

tablets " were omitted.

Strychnine, atropine, cinchona rubra and gentian.—The first two of these drugs are given both byhypodermic injection and in the form of a mixture,

the last two in mixture only.

The solution of strychnine for hypodermic use is

:

Strychnine nitrat. . . . . gr iv

Aq. distillat adjj

Dose, rn. ij to ix or x.

The solution of atropine for hypodermic use is :

Atropin. sulphat gr. j

Aq. distillat ad 3j

Dose, in. j to viij or ix.

The prescription for the mixture, commonlyspoken of as the " tonic," is :

Liq. cinch, cone. (Fletcher) . . n).xxiv

Liq. gentian co. cone. „ . . n\ viij

Sol. strych. nit. (gr. iv ad 3 j) • t>1 j

Sol. atrop. sulph. (gr. j ad 3j) ti\ j

Glycerini . . . . • 3JAquae ad . . . . • 3 ss

To be given three to five times daily diluted with

water.

The injections and mixture may be used in two

different ways, and with two partly different objects.

(t) They may be used for the purpose of breaking

the patient off from drinking, as well as for maintain-

ing him for a time in a state of indifference as regards

alcohol. This was their original mode of use in the

sanatorium. On admission the patient was at once

put on the injections and the mixture. Five minims

228 ON ALCOHOLISM

of the strychnine solution and two or three of the

atropine solution were administered in the one

injection immediately after breakfast, luncheon and

dinner: at the same time the mixture was com-

menced and given three to five times a day and

continued throughout unchanged. Every two or

three days the doses of strychnine and atropine

solutions in the injections were raised by ny, until

the physiological effects of the drugs—slight muscular

twitchings, increased reflex activity, dilatation of the

pupils and dryness of the mouth and fauces, were

apparent. The maximum doses of the two solutions

would vary, but they would rarely exceed n\. x of the

strychnine and v\ viij of the atropine solution.

Having arrived at the maximum, the dosage would

be steadily reduced each day, but the atropine would

be reduced more rapidly than the strychnine, so that

at the end of from eighteen to twenty days the

patient would be having strychnine only injected.

This would then be continued in doses which varied

with circumstances.

Under this plan the desire for alcohol steadily

subsides. Indeed, upon its success depends most of

the evidence which goes to show the efficiency of

these drugs in alcoholism. Moreover, there is no

doubt that the plan leaves a deep and rather lasting

impression on the patient. But it has counter-

balancing disadvantages. In some few cases delirium

results (three in this sanatorium). As to the exact

nature of this delirium—whether it is to be regarded

as atropine delirium, or as delirium tremens modified

by atropine—there remains some doubt. Also it is

uncertain which of the two factors—the strychnine

REGULATION OF INJECTIONS 229

and atropine injections, or the rapid cessation of

drinking which results from these injections—is

chiefly responsible for the delirium.* The majority

of cases, of course, escape delirium ; but even then

there are apt to arise distressing nervous symptoms,

such as increased tremulousness of the muscles,

insomnia and a vague, but none the less real, feeling

of apprehension, especially at night, which last maydemand the constant services of a special attendant

for a time. These unpleasing effects seem inseparable

from the use of moderately large doses of strychnine

and atropine in patients who are still drinking, and

whose nervous system has been for some time

weakened and disarranged by continual soaking in

alcohol : they have always arisen in some degree

whenever the above method has been revived in the

sanatorium. Nevertheless, they are a source of

worry and anxiety to the staff rather than of danger

to the patient ; and I am inclined to think that in

private practice, where the patient remains in his

own home amongst his accustomed surroundings,

and where, consequently, the physician has little to

depend upon but the drugs and his personal influence

exerted at intervals, this bolder method will in most

cases yield the better results. Many medical men are

using strychnine and atropine for alcoholism in

the patients' own homes, and are kind enough to

keep me informed from time to time as to their

results. And I have been struck by the fact that

in the unsuccessful cases (which are, of course,

quite frequent) the almost uniform cause of ultimate

* In one of the three cases mentioned the delirium was un-

doubtedly an atropine delirium.

230 ON ALCOHOLISM

failure has been failure to obtain a satisfactory start

:

patients who have been successfully weaned from

drinking have done, on the average, well. It may be

better, therefore, in private practice to risk discomfort

and additional trouble, even the chance of an attack

of delirium, in view of the greater probability of

tiding the patient over the most critical period in his

treatment.

But in a sanatorium specially organised for the

management of alcoholism such considerations have

little weight. Patients are surrounded by so manysafeguards, they can be influenced in so manydifferent ways, that the danger of failing to make a

satisfactory start is negligible. Besides which wehave a much more rapidly efficient, though less

enduring, drug in apomorphine. One can well

afford, therefore, to avoid all risks of complications,

and at the same time to consider the comfort and

convenience of those concerned, both patients and

staff. All these objects have been attained during

recent years by adopting the plan now to be

described.

(2) Only in patients who have quite ceased to

take alcohol for a week or several days before

admission, and who are eating and sleeping without

artificial aids, are the injections and cinchona mixture

commenced at once. In all others the preliminary

treatment is as already described under various

heads. Only after two or three days of complete

abstinence, and then only when the patient has

enjoyed one good night's sleep without hypnotics

—

in fact, only when the patient has already " turned

the first corner "—is the systematic course of injec-

REGULATION OF INJECTIONS 23I

tions and cinchona mixture commenced. Moreover,

other precautions are taken : the mixture is com-menced on the first day, the injections only on the

second : the initial doses of strychnine and atropine

are much smaller, the rise in dosage more gradual,

the maximum lower. At the same time the whole

course extends over a longer period. Under this

revised plan—which is equally efficient as regards results

—complications and distressing symptoms are unknown.

The following scheme represents the dosage of an

average case

:

First week.—Gradual rise up to ii\y strychine

solution and 4 v\ atropine solution.

Second week.—Continued rise up to v\yi] strychnine

solution and myj atropine solution.

Third week.—Doses maintained at about irjyij

strychnine solution, and myj atropine solution.

Fourth week.—Dose reduced to n^vj strychnine

solution and mv atropine solution.

Fifth week.—Dose reduced to v\y strychnine solu-

and v\\v atropine solution.

Sixth week.—Gradual reduction of dosage downto m.ij and v\] respectively on the day of leaving.

In the case of patients who remain in the sana-

torium for eight, twelve, or more weeks—cases

recently becoming much more numerous—the gradu-

ation scheme is modified and extended accordingly.

Sometimes the injections are then omitted for a

week and then recommenced, or they may be given

on alternate weeks ; or again, less frequently during

the day.

With the dosage described, it is rare for idiosyn-

crasy to call for any modification. Theoretically,

232 ON ALCOHOLISM

atropine might conduce to glaucoma ; and it is

well, therefore, to test the tension of the eyeball in

elderly persons. The larger doses of atropine occa-

sionally cause cutaneous irritation : when this is so

severe as to cause loss of sleep (the irritation is always

worse at night) the atropine is omitted from the

evening injection. Again, some patients are unusually

intolerant of strychnine : in them the drug, even in

quite moderate doses, may cause so much increase

of reflex irritation that sleeplessness results. In

such it is necessary, and nearly always sufficient, to

omit the strychnine from the evening injection, and

there are other less common occasions calling for

modification in the composition of the injections.

For example, in a. few patients anything but a quite

small dose of atropine causes temporary confusion

of thought, forgetfulness, and occasionally mental

depression. It may be as well to point out also that

given just before meals this drug interferes materially

with the digestion of starch, through its action

in checking the secretion of saliva. Finally, it is

to be remembered that strychnine is cumulative and

may have to be omitted occasionally. Atropine, on

the other hand, seems to lose its influence somewhatthrough continued use.

As regards the tonic mixtures there is, so far as I

am aware, only one idiosyncrasy which may call for

its omission or alteration. There are a few persons

in whom cinchona (or even quinine) in any form

always produces dyspepsia. Three such patients

have come under notice in the sanatorium in the last

six and a half years.

Reference may here be made to the great

ADVANTAGES OF HYPODERMIC MEDICATION 233

superiority of the hypodermic over other methods of

drug administration. Absorption is rapid and certain :

one knows exactly when the physiological influence

of the drug will have reached its maximum, and

when it will, for all practical purposes, have ended.

Were the drugs given by the mouth, one would often

be constrained to omit them for a day or two, instead

of for a few hours. A final advantage is the suggestive

effect : this is by no means inconsiderable.

There is a prejudice amongst some members of

the profession against the use of the hypodermic

needle in the case of alcoholists : one medical man is

accustomed to state as his opinion that anyone giving

a hypodermic injection to an alcoholic inebriate

deserves to be shot ! There is no need to question

the sincerity of those who hold these views, but it is

open for us to ask for justification. Does not the

whole argument arise from a confusion of thought ?

It is, of course, admitted by all that morphine

euphoria comes on more rapidly and is more intense

(in proportion to the dose) when the drug is ad-

ministered hypodermically. And it may further be

admitted that morphinists do " fall in love" with the

needle. But it is silly to contend that the same

occurs in patients whose experience of hypodermic

medication is limited to drugs like strychnine and

atropine, which, so far from causing euphoria, act, if

anything, in an opposite direction. And, indeed,

experience teaches that such patients tend to acquire

a dislike to the hypodermic needle.

Apomorphine, on the one hand, and strychnine

and atropine on the other, have both their places in

the treatment of alcoholism. The outstanding ad-

234 0N ALCOHOLISM

vantage of apormorphine is the exceeding promptness

of its action, whether given in large emetic, or merely

small and perhaps barely hypnotic, doses. To alter

completely the whole mental aspect of the case bymeans of apomorphine injections is only a matter

of minutes, and this whether emesis and sleep are

induced or not. Now, in order to afford relief from

the alcoholic craving by means of strychnine andatropine injections, two or three days at least of

steady medication are required. The difference is

remarkable. Nevertheless, there is something to be

said on the other side. As against the unfailing

promptness of its action must be placed the evan-

escence of the effects of apomorphine. Although in

some cases six or even eight hours' sleep follows an

injection, yet, as I have said, I do not believe that

the hypnotic effect endures for more than from

two to three hours. Hence its utility in insomnia

is limited to those cases in which the difficulty

consists in an inability to go to sleep—not to

remain asleep. And the freedom from the dipsomaniac

craving conferred is equally fleeting. Hence the

necessity for frequent repetition. On the other

hand, the steady diminution in the desire for

alcoholic narcotisation set going by strychnine and

atropine is much more enduring. Generally speaking,

however, the more the patient's craving approxi-

mates to the dipsomaniac craving, the more is it

expedient to rely on apomorphine as against other

drugs.

Morphine tartrate.—Rarely, indeed, can there be

any valid excuse for prescribing morphine, especially

hypodermically, in cases of alcoholism, whether

RARE USE OF MORPHINE 235

inebriate or sober : the dangers inseparable from the

use of this drug are too great. But emergencies do

arise in which a morphine injection may fairly be

regarded as the lesser of two evils, one of which is

inevitable. Such emergencies, I imagine, are less

frequent in sanatorium than in private practice. Amedical practitioner may suddenly be called upon to

look after a dipsomaniac, who for the time is highly

dangerous to others, or, again, to a patient suffering

from mania a potu who is always more or less

dangerous ; and it may be that adequate assistance

in the shape of male attendants is not available.

Again, a dipsomaniac or pseudo-dipsomaniac patient

may suddenly fall into a state of acute melancholia, in

which condition he is highly dangerous to himself

;

and here also adequate protection by others may be

unattainable. In such emergencies full doses of

morphine, given hypodermically, combined or not

with other drugs more efficient as hypnotics, maysave the situation, and even avert a tragedy. I

believe it is a fact that suicide in a patient who is

fully under the influence of an opiate of any kind is

practically unknown ; and, from my own observation,

I have little doubt that the homicidal inebriate can be

rendered temporarily harmless to others by adequate

morphinisation. Probably, however, apomorphine

is in this case more prompt and temporarily

efficient.

But it is obvious that morphine should be regarded

solely as a pis oiler in emergencies. And when so

used the name or nature of the drug must never be

divulged. In the few cases in which I have been

driven to use it, I have usually combined with it in

236 ON ALCOHOLISM

the one injection a slightly emetic dose of apo-

morphine. The green colour of the mixed solution as

well as the immediate unpleasant effects of the in-

jection suffice to prevent suspicion of the character of

the drug from leaking out. Moreover, such injections

have always been given by myself: I have refrained

from trusting the name of the drug even to the

trained nurse, male or female, in charge of the case.

Rationale of the action of drugs used in alcoholism.—It is assumed by some that drugs are necessarily

useless for the purpose of combating the alcoholic

craving, which they consider essentially a moral

disorder. Such a standpoint seems unscientific.

Alcoholism cannot be proved to be solely a moral

affection. Nor would it of necessity follow that

drugs are useless if it could be so proved. Atany rate, it is certain that, without the unrestricted

right to the use of drugs, any attempt to carry

on a sanatorium in which all the patients retain

the full rights of citizenship would be futile : the

institution would shortly be empty, or nearly so.

The beneficial action of most of the drugs employedis quite obvious, even to the unskilled and superficial

observer. This applies to alcohol, apomorphine,bromide of sodium, capsicum, the various hypnotics,

and to morphine. But it is questionable whethertheir action in any instance can yet be fully explained

on physiological lines. On the other hand, the

beneficial action of the course of strychnine andatropine injections, as they are at present given, is

not so obvious—though it was obvious enough whenthese drugs were given from the commencementaccording to the first of the two methods described

DURATION OF TREATMENT 237

(p. 227). I can only say that I ascribe an appreciable

part of the freedom from the wish for alcohol whichpatients undoubtedly experience while in the sana-

torium, and especially in the latter stages of their

course of treatment, to the physiological influence

of these drugs systematically administered. And in

making this statement I do not ignore the influence of

the regularity of attendance incidentally necessitated

by the injections, nor the influence of the patient's

belief in the efficacy of the injections. Deprived of

these influences, physiological and psychological, I

am convinced that nothing like the amount of

personal liberty which patients now enjoy, could be

safely permitted.

Duration of Treatment; Question of After-Treatment ; Parting Advice.

One of the primary objects of the Norwood Sana-

torium is to induce patients to enter as early as

possible in the progressive development of the habit

or disease of alcoholism ; a short term in an early

stage is more likely to be of permanent benefit than

a longer term subsequently. To this end, no effort

is spared to meet and defeat in advance the objec-

tions to institutional treatment which are inevitably

proffered by alcoholists, more especially incipient

alcoholists. Prominent amongst such objections is

the plea that the necessary time cannot be afforded.

Hence, it happens that the duration of treatment in

the sanatorium rarely approaches the ideal. It is

regulated far more by the time at the patient's dis-

posal than by the advice of the physician. And

238 ON ALCOHOLISM

generally it must, I think, be regarded as inadequate :

at any rate, inadequate for the best result we should

be justified in anticipating. Nevertheless, it is

expedient to have a minimum period, and this of

recent years has been fixed at six weeks. Of course,

many patients are accepted for shorter periods ; but

always more or less under protest, and after full

explanation.

After a very few days (the number of which varies

within narrow limits), counting from the date on

which he received his last dose of alcohol, the

patient will express himself as absolutely well, and

entirely free from all desire for alcohol. Further, he

is then convinced in his own mind that he will

always in future remain a total abstainer; and often

some difficulty is met with in persuading him that

further residence is necessary. Obviously, were the

patient's judgment on this point sound, further resi-

dence would be unnecessary, and the average duration

of treatment in the sanatorium would be something

between a fortnight and three weeks. But his judg-

ment is wrong, for it is a matter of experience that

patients who leave at this stage almost invariably

relapse, and relapse quickly ; whereas he whoremains for several weeks subsequently, although he

may exhibit no obvious alteration in his con-

dition, has an average chance (see statistics) of

remaining an abstainer after leaving.

For a considerable time I failed to discover the

reason for the discrepancy. Something had to beallowed for the extended experience of alcoholism

which the patient gained through remaining in the

sanatorium and associating with others of his kind;

DAYS OF RECURRING DESIRE 239

but this alone seemed inadequate. Now the reason,

though not very manifest, is simple. On close inquiry,

it will be found that the complete freedom from the

desire for alcohol which begins—often quite suddenly

—a few days after absolute abstinence has been

instituted, is not entirely continuous. A patient mayhave two or three days on which he wonders whyhe ever "touched the beastly stuff," and yet on the

fourth he finds himself regarding an alcoholic drink

of some sort as decidedly less undesirable : he has,

in fact, a renewed " hankering " after liquor. This

does not last long, however ; and next day, perhaps

even later in the same day, he reverts to his previous

attitude of entire indifference. Subsequently, perhaps

in a week, he may again find himself pondering on

the subject of alcohol. On this occasion, however,

he recovers more rapidly. And later, again, he mayexperience a third, or even a fourth, attack of this

mild kind of desire. But each will be less severe, less

prolonged, and separated from the preceding one by

a longer interval. It is no doubt on one of these

recurring days of weakness that the patient would

have relapsed had he left the sanatorium when he

first felt free from the alcoholic craving ; and it is

on their account that it is essential for him to prolong

his treatment for several weeks. Incidentally, it

may be mentioned that the same recurrence of the

craving, but in much more marked degree, occurs in

morphinists who have recently been weaned from

their accustomed drug.

An exception to the rule that patients should

remain at least six weeks is made in the case of sometrue periodic dipsomaniacs. In those rare examples

24O ON ALCOHOLISM

of this variety of alcoholism in which the intervals

are exactly equal, and in which consequently it is

possible to fix beforehand the exact date on which

the succeeding paroxysm will commence, it is often

expedient for the patient to leave after a fortnight

and re-enter for other fortnights as often as may be

necessary. After a fortnight's residence, the patient,

though not perhaps at his best, is probably safer

from the danger of relapse than he will be subse-

quently. He is certainly safer than he will be at the

near approach of the time when his next paroxysm

is due. By entering just before the time of the

expected paroxsym, or on the earliest indication of

the commencement of the premonitory stage, he can

count upon each attack being completely aborted.

And it is conceivable that, after he had remained free

from paroxysms for a certain time, the tendency to

recurrence would be broken.

Even in true periodic dipsomania, however, it is an

open question whether the patient on his first ad-

mission to the sanatorium should not remain for a full

course of six, or even more, weeks. For several cases

have occurred in which this plan has resulted in the

omission of his succeeding attack, or even his twosucceeding attacks. It would seem from this that the

periodicity of dipsomania is not always so inevitable

as we are inclined to think. At least, it encouragesthe hope that this rare affection will not always be so

hopeless as now appears.

Question of after-treatment.—How it has arisen it

is difficult to say, but there is a very general idea

that, on the completion of the course of treatment in

the sanatorium, there should succeed some sort of

QUESTION OF AFTER-TREATMENT 24I

" after-cure." Apparently it is thought that the

sanatorium course is in some way debilitating, andrequires to be followed and counteracted by a further

tonic course. The " after-cures " thought of vary

widely. Sometimes prolonged residence with a

medical man, or in an institution where no drugs are

used, is suggested ; or a trip to the seaside or someinland watering place. Others, again, seem to have

great faith in a long sea voyage. This last may be

straightway condemned without hesitation or quali-

fication. I speak here from ample experience. Onlyin one instance have I known a sea voyage result in

anything but failure and retrogression. Except in

the case of a strictly teetotal ship, now by no means

easy to find, the patient is always worse at the end of

his voyage than at the beginning—a result which

could be safely predicted by all who are familiar with

the social conditions of life aboard ship. Indeed,

many a moderate drinker habitually indulges to

excess whenever he travels by sea.

The fact is that the sanatorium course of treatment

requires no " after-cure ": the course itself is tonic in

effect. And I am convinced that, on the average,

that patient does best who, on leaving this institu-

tion, goes straight back into harness and starts at

once, con amove, to regain some of the leeway for

which his habit has been responsible. It is

unfortunate in many cases that no harness is await-

ing him. He has lost his billet, and on leaving the

sanatorium is forced to start anew. In all such cases

it is in the last degree important that the arrange-

ments for his future should be completed as far as

possible while he is still in the sanatorium. Far better is

16

242 ON ALCOHOLISM

it for the ex-alcoholist that, while subject to this

most severe of tests, he should still be protected in

so far as is possible, by continued residence in a

sanatorium ; for there is no doubt that he is much less

prone to relapse there than elsewhere.

Parting advice.—Originally it was customary to

arrange for a somewhat prolonged interview with the

departing patient. Much well-meaning advice was

tendered him on these occasions, and the details of

his subsequent daily life were rather closely gone

into. But it is to be doubted whether much was

ever gained by this. When all has been said, there

is but one point which it is essential for the ex-

alcoholist to have always before him, which is to

avoid the first drink. This sentence should stand out

before him in the very boldest relief. And it would

seem that to dwell on any other point is but to blur

the importance of this one essential. Long ex-

perience shows that practically all ex-alcoholists

(except some true dipsomaniacs) have sufficient will-

power to avoid the first departure from strict

abstinence, for the anteceding craving—if it can be

called a craving—is but trifling. This is the all but

unanimous verdict of those who have relapsed. Onthe other hand, experience shows with equal clarity

that practically no ex-alcoholist has sufficient will-

power to avoid the second drink (although, of course,

he may defer it). The inference is obvious. And I

think it is expedient that the last word of the medical

superintendent should be—" Never forget for a single

instant the vital necessity of avoiding the first drink."

Moreover, in order to impress this the more deeply, I

have quite seriously suggested that should he at any

PARTING ADVICE 243

time be so unfortunate as to have taken this first glass,

he will be well advised to return to the sanatorium

by the first train if possible, and remain for a time,

if only for a few days.

In this way he will save much worry to his friends

and much misery to himself. Besides which, this

will almost certainly be the most economical course.

Occasionally, I am pleased to be able to report, this

advice has been acted upon and fully justified by the

results.

CHAPTER IX

General results—Fallacies : incomparability of results;incompar-

ability of data—Statistics : percentage of relapses, of cases

stated to be improved, and of abstainers ; known duration of

abstinence following treatment ; results in individual patients

—

Some factors bearing on prognosis : heredity ; sex ; age ; form

of alcoholism.

One of the chief sources of fallacy in medical

statistics, namely, paucity of data, does not materially

affect statistics of alcoholism : the data offered are

practically always sufficiently numerous. Two other

sources of fallacy, however, do interfere seriously

with the conclusions which might otherwise be

drawn. These are (i) incomparability of results,

chiefly dependent on varying interpretations of the

word " cure "; and (2) incomparability of data or

clinical material, dependent in the main on the

varying conditions under which different series of

patients come under treatment.

To the intending patient or patient's friend

making preliminary inquiries at the sanatorium, it

seems a simple matter to answer the inevitable

question, " How many do you cure ? " In reality

this question is unanswerable except with numerousreservations, and then only after prolonged explana-

tion. A celebrated divine once delivered a sermon

INCOMPARABILITY OF RESULTS 245

entitled, " The terrible imposture and force of

words." I do not know that he selected the word" cure " as one of his illustrative examples, but I amsure he could have chosen none better for his pur-

pose. Applied to any disease or accident, the term

bears numerous interpretations, while in the case of

alcoholism, it is used in so many different senses that

it is always doubtful whether any two parties to an

argument on this subject have in mind anything

like the same result. A few of the different

interpretations of the word may be mentioned.

(1) The term is often used to indicate a system of

treatment irrespective of the result of that treatment,

as in the " grape cure," the " water cure," etc. I

am often asked to describe the nature of the " sana-

torium cure." Obviously the inquirers mean treat-

ment.

Used in this sense the proportion of patients

" cured " in the Norwood Sanatorium would, of

course, be 100 per cent.

(2) A patient, who for many months or longer has

been drinking hard, and is quite unable to cease

doing so, enters the sanatorium. In the course of a

few weeks (six or eight) he has not only ceased to take

alcohol, but is enjoying his food, and is sleeping well

throughout the night without hypnotics ; and that

even in spite of the use of drugs, the tendency of

which is rather to prevent sleep. The albuminuria

present on admission has cleared up, all his func-

tions are being normally performed, and he has

regained his pleasure and interest in life. More-

over, he confidently states that he has not the least

inclination to resort to alcoholic stimulation, and

246 ON ALCOHOLISM

intends never to do so again. A few patients even

at this stage state that they have acquired an actual

distaste for alcohol in any shape or form.

Many refer to such a case as a " cure," meaning

thereby that the patient has been "cured" of his

craving for alcohol. Should he later on relapse into

drinking, they say he is suffering from another attack

of alcoholism, or has re-created his craving and

requires to be " cured " again. No doubt, in a

sense, this is true. Those so using the word point to

cases of rheumatism, gout, eczema, and other recur-

rent affections. They argue that no one would

refuse to apply the term " cure " to successfully

treated attacks of these disorders, simply because the

patient might probably suffer subsequently from a

second or third attack.

Used in this sense of the word the proportion of

patients treated in the Norwood Sanatorium for

periods varying from six to eight or more weeks, and" cured," would be over 90 per cent.—an excellent

advertisement in its way.

(3) Many hold, however, and with reason, that it is

comparatively easy for a patient to remain an

abstainer while he is in the sanatorium surrounded

by safeguards, moral and other. They maintain,

therefore, that it is not correct to consider him" cured " until some time after he has left the insti-

tution—until, that is to say, he has shown that he

can withstand the influences which originally con-

duced to his habit. The question then arises : whatfurther time should be allowed to elapse before it is

fair to pronounce him " cured " ? Herein no twoseem to agree. Some say three, others six, nine, or

DEFINITION OF THE TERM CURE 247

twelve months. Others, again, hold out for twoyears, and yet others for three, four or five years.

Obviously, the duration of this observation period is

purely arbitrary. Consequently the statistical state-

ments of different physicians, lay observers andinstitutions are rarely, if ever, comparable. What is

quite certain, however, is that, other things being

equal, the longer the period of observation accepted

as adequate, the smaller the percentage of "cures."

Thus, in the statistical results of the Norwood Sana-

torium, it will be seen that there is a wide variation

in the percentages of those who remain abstainers at

three, six, nine and twelve months respectively,

counting from the date on which they left the

institution.

(4) The three definitions ahove indicated depend

upon the simple fact of total abstinence for a shorter

or longer period : they take no notice of the patient's

feelings or frame of mind during his abstinence. Hemight, for example, crave for alcohol more or less

every day or from time to time, and yet remain an

abstainer through the exertion of his power of will.

Nevertheless, he would be entitled under the defini-

tion to be written down a " cure." Now it might

reasonably be claimed that such a result hardly

deserves the term. Therefore we should have to

add to the fact of abstinence a note to the effect that

all craving, or even desire, had been, and still was, in

abeyance.

I am unable to give figures showing the percentage

of " cures " under this more limited definition of the

term. No doubt, however, it would be smaller than

the percentage of all those who remain abstainers

248 ON ALCOHOLISM

It would not be much smaller, however, for certainly

in the great majority of instances in which he is

attacked by the craving for alcohol, the ex-inebriate

abstainer succumbs thereto. Fortunately, in point

of fact, he is quite rarely so attacked, so long as he

continues to abstain.

(5) In all the four definitions above indicated, it

is assumed that a patient who remains a total ab-

stainer is convalescent from the habit or disease of

alcoholism : it is admitted that his continued free-

dom depends absolutely upon the condition that he

never takes alcohol in any form. But it may well be

questioned whether we have any real right to con-

sider such sharply conditioned freedom from alcoho-

lism as a cure of alcoholism. For my part, I think

we have no such right. To my mind, an alcoholist

could be said to be cured only (a) if he has fully

recovered from the numerous tissue degenerations

and physical and psychical weaknesses which he had

acquired : (b) if he remained free from any special

desire for alcoholic euphoria ; and further (c) if he

had re-acquired the capacity to indulge in alcoholic

beverages in moderation from time to time, without

the least desire to indulge therein to excess, or even to

continue the indulgence.

Accepting this last definition of the term, it can

safely be asserted that no alcoholist is ever cured

—

the proportion of patients " cured " in the NorwoodSanatorium at any rate is o per cent.

It is clear, therefore, that the term " cure " is used in

such extremely diverse senses that, when applied to the

sanatorium results, the proportion of " cures" is found to

vary from ioo per cent, to o per cent. Could there be

INCOMPARABILITY OF DATA 249

any stronger reason for abolishing the use of theterm in Mo ? I think not. At any rate, that is the

course which has been adopted in compiling thestatistics which follow.

At the same time, many other of the terms applied

to the results of treatment in alcoholism seem evenmore objectionable : examples of these are wordslike "improved" and "doing well." Such havereally no clear meaning at all. For with the rarest

exceptions, alcoholists after treatment either remain

abstainers or frankly relapse into their former con-

dition, if, indeed, they do not always become worse.

The only remaining course, therefore, is to abandonall qualifying terms and divide all past patients into

two classes, namely, (1) those who were still

abstainers at the date of the last information ; and

(2) those who have relapsed at a certain date. This

is the course which has been followed, with the

exception that it has been found necessary to retain

a third place for those who are stated to be improved.

This third class, however, is so small as hardly to

affect the results, and it may be regarded as due in

the main to inadequate or imperfect information.

The statistical fallacies arising from varying inter-

pretations of the term "cure," may be looked upon

as fallacies due to incompat-ability of results. The other

equally serious source of fallacy arising from incom-

parability of material or data may now be considered.

Whether a disease or not, alcoholism (as already

pointed out) obeys at least one of the canons which

govern disease in general : other things being equal,

it is remediable inversely as its duration. Now it is

always recognised that alcoholists as a class are very

250 ON ALCOHOLISM

averse from admitting that they have acquired a

craving for alcohol. It is not until they have madeseveral futile attempts to cease drinking that they

begin to admit their condition, even to themselves.

And there may be a long interval between that stage

and the next at which they are prepared to make the

same admission to others. Even when they have

arrived at the latter stage, they may still be unpre-

pared to consult a medical man, more especially the

family medical man. They may perhaps be willing

to take some much-advertised nostrum which they

can obtain through the post without disclosing their

identity. But only when this also has failed will

they consent to see a physician. And even then

they will usually insist upon being treated in their

own home.

Treatment, in these circumstances, may or maynot be successful. But it is certain that, until it has

failed, most patients will not consent to enter anykind of institution, even one where they are under

no legal compulsion. Finally, if it takes so muchtime, so much consideration, and the experience of

so many failures, to induce them to enter a voluntary

sanatorium, it stands to reason that the time whenthey will consent to sign away their liberty under the

Inebriates Act and enter a licensed retreat will bestill further deferred.

Hence it happens that series of patients treated

respectively by advertised nostrums, by private

medical men, in free sanatoria, and in retreats

licensed under the Act, are, on the average, in very

different stages of the habit or disease. There is, therefore,

a wide variation in their respective prognoses ; and it is

STATISTICS 251

entirely futile to compare these different series with each

other, at least with the object of determining theefficiency of the different methods of treatmentadopted in each.

In the statistics which follow, therefore, no attemptis made to compare the sanatorium results with those

of other institutions, or with those following other

methods of treatment.

Statistics.

The figures are arranged with the object of show-ing as clearly as possible what may fairly be expected

from a short period of residence, plus medical treat-

ment, in the sanatorium.

In order to avoid any possible charge of unfair

selection of cases, all the admissions into the institu-

tion since its re-organisation under the Advisory

Medical Committee in 1905 have been included.

Total admitted between the middle

of 1905, and December 31st, 1911 . 868

Remaining in the sanatorium on

December 31st, 191 1 ... 18

Number discharged or died (847 and 3

respectively) 850

Number of non-alcoholic cases . . 106

The 106 non-alcoholic cases may be classified as

follows : Morphine 72, morphine and cocaine 3, co-

caine 2, opium and laudanum 4, chlorodyne 1,

veronal 2, paraldehyde 1, chloral 1, tobacco 1. Theremaining 19 cases were not cases of drug habit.

They comprised psychasthenia and neurasthenia 8,

neuralgia 2, insomnia 1, dementia, hypochondriasis

252 ON ALCOHOLISM

and delusional insanity 3, atypical epilepsy 1, gastral-

gia 1, dyspepsia 1, colitis I, and chronic bronchitis 1.

Number of alcoholic cases discharged

or died (741 and 3 respectively) . 744Number of these not treated by the

special course for various reasons . 293

Such reasons were as follows : 186 were cases ad-

mitted as emergencies in a condition of more or less

acute alcoholism : all these left within a week or two

of admission, after having recovered from the out-

break. Most of them were dipsomaniacs or pseudo-

dipsomaniacs, and many of them were admitted on

several occasions : 39 left permaturely for a variety

of reasons, such as business necessities, domestic

worries, or lack of means : 23 turned out to be insane

and therefore not suited for special drug treatment

—many of these were transferred to more fitting

institutions : 7 were suffering from serious physical

illness on admission, which illness was held to render

inexpedient or unnecessary the administration of the

special course—2 of these 7 died in the Institution :

4 were requested to leave through refusing to conform

to the regulations : 1 was arrested : 12 refused any

medicinal treatment : 12 were abstainers on admis-

sion—these were old patients who had remained well

since treatment and who elected to spend some of

their vacation in the sanatorium, partly, no doubt,

from precautionary motives ; while 9 were more or

less permanent boarders.

Number of alcoholic cases more or less

fully treated by the special course anddischarged 451

GENERAL RESULTS 253

Number lost sight of immediately on

leaving nNumber followed up more or less

recently 440There remain, therefore, 440 cases by which to test

the efficiency of sanatorium residence plus the special

course of treatment in use during nearly six and a

half years ending December 31st, 1911. These

440 cases may be divided into the following three

classes

:

(1) Cases which are known to have relapsed.

These are 200 in number, or 45 per cent, of the

whole. In 22 the relapse occurred during the course

of treatment in the sanatorium (strictly speaking

these cases should be described as failures to cure,

not as relapses) : in 11, almost immediately on

leaving : in 32, in one month : in 13, in two months

:

in 18, in three months: in 14, in four months: in

12, in five months : in 18, in six months : in 8, in

seven months: in 5, in eight months: in 8, in nine

months: in 4, in eleven months; and in 11, in one

year. In 9 cases the relapse occurred in between

one year and one year and a half: in 10 in between

one year and a half and two years ; and in 5 not

until after two years.

(2) Cases stated by their medical attendants,

employers or friends to be improved or much im-

proved, but not total abstainers. The number is

12, or 27 per cent, of the whole. The reports con-

cerning these 12 cases have been received at the

following periods since the patients left the sana-

torium : 1 case, three years: 1, one year and eight

months : I, one year and seven months : 2 cases, one

254 ON ALCOHOLISM

and a half years : i case, one year and five months

:

I, one year : i, eleven months : i, nine months : 2

cases, three months ; and i case, one month.

(3) Cases which remained total abstainers whenlast heard of. These are 228 in number, or 51 '82

per cent, of the whole. The most recent reports

concerning these cases have been received at the

following periods since the patients left the sana-

torium : 49 cases, two years and over : 29, between

one year and a half and two years : 21, between one

year and one year and a half: 20, one year : 2, eleven

months : 4, ten months : 8, nine months : 2, eight

months : 5, seven months : 12, six months : 4, five

months : 10, four months : 14, three months : 14,

two months : 24, about one month ; and 10, less

than one month.

The above figures call for some explanatory

remarks. For the sake of simplicity the term" cases " has been used in the sense of admissions.

It happens, therefore, that some patients appear morethan once in class 1 : in other words, some patients

account for more than one relapse. It also happensthat some who appear in class 1, appear again in class

3 : in other words, some patients account for both a

relapse and a success. But it is obvious that no patient

can appear more than once in class 3, since all the

results there set down are drawn from the last infor-

mation supplied and from that only. So far, there-

fore, the system adopted tends to make the results

of the treatment appear a little worse than theyreally are. On the other hand, many of the patients

in class 3 have not been heard of, or from, for someconsiderable time ; and it is, of course, highly pro-

KNOWN DURATION OF ABSTINENCE 255

bable that some of these have already relapsed. Tothis extent, then, the system adopted tends to makethe results of treatment appear somewhat better than

they really are.

Class 2 is unimportant, and should not, in myopinion, be regarded very seriously. Some would

contend that it should be incorporated with Class 1,

—my own sympathies would be with these. But

there are some who are prepared to maintain that

some of the cases included in Class 2 are moreproperly to be regarded as " cures " than any of the

cases which constitute Class 3. I am always doubt-

ful, however, as to the accuracy of the information

supplied in the majority of the cases in Class 2.

Since the statistician is altogether dependent on the

information supplied—on hearsay evidence, that is

to say—it is obvious that the results in this class

should be received with caution.

The statistical system adopted is open to manyobjections, but so undoubtedly in even greater degree

would be any alternative system which could be

selected. It can at least be claimed for the chosen

system that the terms are accurately defined, and

that fallacies due to the operation of the personal

factor—the personal factor of the statistician—are

largely excluded.

Known duration of abstinence following treatment

in 428 cases.—By adding together classes 1 and 3

we obtain some idea as to what may be reasonably

expected from a single course of treatment in the

sanatorium. This is shown in the subjoined column :

No time 22

Less than one month 21

256 ON ALCOHOLISM

About one month . . . . . 56

Two months . . . . . .27Three months ...... 32

Four months ...... 24

Five months . . . . . .16Six months....... 30

Seven months 13

Eight months ...... 7

Nine months . . . . . .16Ten months ...... 4

Eleven months ...... 6

One to one and a half years . . . .61One and a half to two years . . . -39Two years and over . . . . -54

In considering these figures it must be remem-

bered that in none of the cases has a period of

much more than six years elapsed since the treat-

ment terminated : that many cases have been lost

sight of, though still abstainers when last heard of;

and that many more have not long left the

sanatorium.

Obviously it is safe to infer that in any series of

100 consecutive cases fully treated for a period of

from four to six weeks, 70 would remain abstainers

for at least three months, 53 for at least six months,

42 for at least nine months, and 35 for at least one

year. The percentage of patients lost sight of after

one year increases so rapidly that no useful purpose

would be served by proceeding further.

The above figures indicate the very least we have

a right to expect ; for they would remain true even

if all the 228 cases embraced in Class 3 and reported

as still abstainers, had relapsed immediately after the

information was received. This is, of course, a con-

FACTORS BEARING ON PROGNOSIS 257

tingency which is not to be entertained. It follows

that the actual results are very much better—howmuch better, however, there are no means of deter-

mining.

Results in individual patients.—Up to this point the

term " cases " has been used in the sense of admis-sions. The 440 admissions are found to represent

390 separate patients. Of these, 137, or 35*1 per

cent., were drinking when last heard of: 10, or 2'6

per cent., were said to be improved ; while 243, or

62*3 per cent., were abstainers. It is understood that

several of these patients had undergone treatment in

the sanatorium on more than one occasion.

Some Factors bearing on Prognosis.

A very large number of factors enter into the

causation, and hence have a bearing on the prognosis,

of alcoholism. Many of these are elusive in their

nature, and attempts to deal with them in detail

lead merely to psychological tangles. Others are so

indeterminate as to maketheirstatistical management

impracticable. In a small minority of cases, how-

ever, there has been a definite pathological condition

which has clearly been the starting-point of the

habit. The best known and commonest of these is

dysmenorrhoea. Others are asthma, dyspepsia, the

innumerable varieties of mental depression, and all

the functional disorders which have their starting-

point in eye-strain arising from some uncorrected

error of refraction. Obviously the prognosis of the

alcoholism will depend largely upon the removability

or otherwise of such determining factors.

A few conditions, however, which may be regarded

17

258 ON ALCOHOLISM

as factors in alcoholism, do lend themselves to statis-

tical treatment. But these are all, with the possible

exception of the last-mentioned, irremovable. Such

are heredity, sex, age, and the form of alcoholism.

Heredity.—It is generally supposed that the

existence of a hereditary tendency to alcoholism

renders the prognosis less favourable. Indeed, it is

not uncommon to meet sufferers who have given up

attempting to abstain because they believed them-

selves inevitably doomed through the faults of their

ancestry. Yet the sanatorium statistics do not

support this view. Of the 225 patients with here-

ditary taint, yj, or 34'2 per cent., had relapsed when

last heard of; while of 165 without known hereditary

taint, 60, or 36*4 per cent., had relapsed. Thus the

results were actually a little worse in the non-here-

ditary patients. The difference shows, at least, that

the existence of a hereditary tendency to alcohol

does not of itself render the prognosis materially

worse than the average.

Yet heredity is undoubtedly an important factor.

And I am inclined to think that its baleful influence

is seen most clearly in the clinical histories of patients,

especially in the rapidity with which the moderate

drinker (for all alcoholists were for a time moderate)

evolves into the chronic alcoholist or inebriate—the

rapidity of the change between physiological and

pathological alcoholism.

Sex.—It is commonly thought that the prognosis

in alcoholism is less hopeful in the female sex. This

may be generally true, but as regards the patients

admitted into, and treated in, the sanatorium, there is no

great difference observable in the results in the two sexes.

SEX AND AGE 259

Of the 390 separate patients, 308 were males and82 females. Of the 308 males, 203, or 65-9 per cent.,

were abstainers when last heard of: of the 82 females,

50, or 6o"9 per cent., remained abstainers. Twocircumstances, however, co-operate to improve the

ultimate results in the female sex :

(1) The sense of propriety is so much more readily

shocked in the case of female alcoholism that women,on the average, seek treatment in an earlier stage

of the habit than do men ; and

—

(2) After their return home, women are more care-

fully guarded than men, and alcohol is more easily

made inaccessible.

There is, therefore, no reason to abandon the view

that alcoholism is in general a less remediable habit

or disease in women. Other things being equal, cases

of equal severity and duration are, in my opinion, of

worse prognosis in the female sex ; and this chiefly

for the reason that the habit has developed in spite

of an environment hostile to alcoholic indulgence.

Similar considerations, of course, explain the relative

infrequency of female alcoholists.

Age.—The subjoined table shows the 390 separate

patients arranged according to age-periods, together

with the respective relapse rates :

Age-periods.

25 and under

No. of

patients.

12

No. relapsed

at last

information.

5

Percentageof

relapses.

4i -66

26 to 35 . IO7 . 46 42-99

36 to 45 . 157 • 45 28-66

46 to 55 . 85 • 3i 36-47

56 to 65 . 25 9 36-00

66 and over 4 1 25-00

260 ON ALCOHOLISM

Paucity of data renders it necessary to exclude from

consideration the first period and last two periods.

Of the three remaining, the best results are seen to

be obtained in the decennium between 36 and 45,

the next best in the following decennium between

46 and 55. These two decennia together contain

the highest proportion of the steady dram-drinking

class—a class in which habit, rather than tempera-

ment, is the dominant factor ; and such patients

yield a higher proportion of permanent recoveries

for at least two reasons, namely

:

(1) Because in temperament they are less impulsive

than intermittent inebriates—and it may be stated

as a general rule that the less impulsive the form of

drinking the more remediable the case ; and

—

(2) Because theysuffer more from physical ailments,

and therefore have more to gain in physical well-

being. The chronic alcoholist is never well : the

intermittent drinker, though often ill, is frequently

in the best of health.

The anteceding decennium, 26 to 35, contains a

higher proportion of impulsive drinkers—dipso-

maniacs, pseudo-dipsomaniacs, and cases approach-

ing in character these forms of inebriety ; and,

moreover, the mere fact of the patient having

arrived at a stage calling for institutional treatment

at so comparatively early an age, may be taken as an

index of marked inherent or temperamental tendency

to alcoholic excess.

Form of alcoholism.—As was to be anticipated the

results are worst in pure dipsomania : of the twenty-

three patients affected with this variety of alcoholism,

twelve had relapsed when last heard of—a percentage

FORM OF ALCOHOLISM 26l

of 52'iy. In pseudo-dipsomania and chronic alco-

holism, the results are approximately equal. Of the

former, there were 122 patients, of whom 42, or

34*42 per cent., had relapsed when last heard of : of

the latter, there were 245, of whom 83, or 33"88 per

cent., had relapsed.

It is worth pointing out that, although pure

dipsomania is quite the rarest form of alcoholism,

the above figures do not give a correct idea of its

relative frequency : it is considerably commoner

than these show. The reason is that most of the

dipsomaniac class come in for treatment of the acute

condition only, and do not remain long enough to

be included in the list of cases fully treated : some-

thing between a week and a fortnight is the usual

duration of their stay in the sanatorium.

INDEXAbstinence, imperative, after

" cure,'' 249— duration of, following treat-

ment, 255— indirect results of, 131

— loss of tolerance after, 169

— permanent necessity for, 191

— phenomena of alcoholism, 113,

139— statistics of, 254— sudden, risks of, 115, 118

— " after-cure," 240

Age, prognosis and, 259

Agoraphobia, 52— relieved by alcohol, 31

Albumen, percentages of, 101, 103,

i°5

Albuminuria, alcoholic, 100, 104

— delirium tremens and, 166

Alcohol, craving for, 61,66, 72, 89,

1Q0, 203, 239— gradual withdrawal of, 104,

in— influence on the circulation,

46,48— intolerance of, 11, 127

— — signs of, 130

— in treatment of delirium tre-

mens, 176

— risks of medicinal use of, 27— tolerance of, 80, 114, 118

— delirium tremens and, 154

— use of, in pyrexial conditions,

23

Alcohol, withdrawal of, 208

gastric symptoms following,

211

Alcoholism, abstinence phenomenaof, 113. '39

— alternating with drug habits,

56"

— chronic or continuous, 80-91

— clinical classification of, 59-91— complications of, 92-112

— convalescence from, affections

arising from, 131

— " cure " of, data and results,

244— debilitating conditions causing,

42— dietetic treatment of, 201

— drugs in treatment of, 217-240— epilepsy associated with, 140—

"45— exciting factors of, 14

— eye-strain, causing, 5c—54— intermittent, 9— intrinsic factors of, 23— mental conditions associated

with, 30— nature of, 1, 5

— prognosis of, 257— prolonged seclusion in, fallacy

of, 179— psychological factors of, 9— recurrent or intermittent, 60-80

— sanatorium treatment of, 4

264 INDEX

Alcoholism, statistics of, 251

— symptomatic of insanity, 29

— symptoms of, 92— temptation factors of, 7

— varieties of, distinctions of, 79,

85

Alcoholists, chronic, charac-

teristics of, 197, 198

— chronic non-inebriate, 83

Amusements, question of, in sana-

toria, 185

Anaemia, associated with alco-

holism, 42

Anorexia following withdrawal of

alcohol, 212

— periodic or recurrent, 132

Apomorphine, advantages of, 234— doses of, 219, 221

— hydrochloride, 218

— injections in dipsomania, 220

— value of, 64

Appetite, loss of, 131, 212

Asthma relieved by alcohol, 47Astigmatism, 53

Atavism, spurious, 22

Atropine, dryness of throat caused

by. 3— injections of, 189

delirium following, 228

— in treatment, 227

— solution, dosage of, 231

— tolerance of, 232

Barmaids, temptations of, 19

Beverages, non-fermented, 192

Bilious attacks, recurrent, 133

Blood-pressure during menstrua-

tion, 34— high, in convalescence, 137

— influence on mental depres-

sion, 35, 39

Boredom, results of, 18, 21

Brain, effects of alcoholism on, 4

Bromide of sodium in treatment,

173, 224

Capsicum for relief of " sinking,"

225

Carbohydrates, absorption of, 134

Catarrh, alcoholic varieties, noChloral hydrate as hypnotic, 225

— tolerance of, 121

Chloroform anaesthesia in deli-

rium tremens, 174

Chlorosis, alcoholic habit set up

by, 43Chronic or continuous alcoholism,

80-91

Cider, relapses and, 75

Cigarettes, risks of, 206

Cinchona rubra in treatment, 227,

230

Cirrhosis, alcoholic, 106, 108

Circulation, effect of alcohol upon,

46,48Classification, clinical, of alco-

holism, 59-91

— of inebriates, psychological

factors in, 9

Claustrophobia relieved by alcohol,

31

Cocaine, tolerance of, 123

Cocainism, alternating with alco-

holism, 56

Commercial travellers, temptations

of, 19

Compulsion and moral tone in

retreats, 181

Complications of alcoholism, gas-

tric, 109

— hepatic, 105

— mental, 94, 95

INDEX 265

Complications, nervous, 98— renal, 100

Constitutional tendencies, 12

Convalescence, alcohol prescribed

in, risks of, 26— from alcoholism, affections aris-

ing from, 131-139Craving for alcohol, 61, 66, 72, 89,

190, 203, 234, 239Criminal responsibility, 127

"Cure," definition of the term, 247" Cures, 1

' incomparability of data

and results, 244— special, 245

Debilitating conditions causing

inebriety, 42

Delirium following atropine injec-

tions, 228

Delirium following morphine ab-

stinence, 120

Delirium tremens, 95, 99, 113

— abortive treatment of, 159— and alcoholic epilepsy com-

bined, 156

incidence of, 155

— before and after admission to

sanatorium, 146-151

— character and duration of pre-

vious drinking, 151

— duration of " incubation "

period, 153

— following sudden abstinence,

"5— mania a potu, distinguished

from, 129

— pathology of, 161

— post-operative, 1 17

— pre-delirious fall in quantity of

alcohol, 152

— preventive treatment of, 173

— prognosis of, 171

Delirium tremens, symptoms and

course of, 169

— traumatic, 163

— theories of, 166-170

— treatment of, 172-174

Dementia, mild, 96Dengue, mental depression follow-

ing, 28

Desire, intensity of, for drink, 10

— recurring days of, 239 (see also

Craving)

Diarrhcea,recurrent or periodic, 133Diet in treatment, 201

— regulation of, during absti-

nence, 134

Digestion, disorders of, following

abstinence, 131

withdrawal of alcohol, 21

1

Dipsomania, 60

— apomorphine in, 220

— chronic inebriety and, 71

— craving in, 89— differentiation of, 79— menstrual, 33— mild, 70— periodic, 239— premonitory stages, 61,65, 77.

79— recurring non-alcoholic, 65— secretiveness in, 68

— statistics of, 252

— sudden withdrawal of alcohol

in, 209

— true, 10

periodic, 61, 63— without premonitory stage, 66

Disease, alcoholism as a, 1

Drinks, fermented, danger of, 193

Drug habits caused by hypnotics,

226

— — operations in, 117

266 INDEX

Drugs in alcoholism, rationale of

action, 236— special, in treatment of alco-

holism, 217-231

— tolerance of, 120-126

Drunkenness, "pathological," n,

127

Dysmenorrhcea, relieved by alco-

hol, 45Dyspepsia associated with alcohol-

ism, 44

Eau-de-Cologne, drinking of, 4Emetic, apomorphine as, 219,221

Emotions, cultivation of, detri-

mental, 20

Epilepsy, alcoholic, 95, 103,113

and delirium tremens com-

bined, 156

— — — — incidence of, 155

— — cases illustrating, 141-144

during abstinence, 140—145

— — prognosis of, 171

treatment of, 172-174

Epileptic mental depression, 36

Euphoria, alcoholic, 3, 5, 10

and pyrexia, 26

Eye-strain, alcoholism due to,

52-54— results of, 50

Example, influence of, 21, 195

Exercise, loss of, result of, 41

Factors bearing on prognosis,

257— extrinsic, 15

— intrinsic, 23

Fermented beverages, danger of,

193

Fevers, alcohol prescribed in, 23

Financial worry, a frequent cause,

16

Fortune, accession to, as a cause,

18

Gentian in treatment, 227

Ginger-ale, 192

Gout, acute articular, 138

— factor of alcoholism, 57

Grief as a factor, 15

Headaches, 50— morning, 136

— sick, recurrent, 133

Heredity, prognosis and, 258

Hobbies, use of, 18

Hyoscine as hypnotic, 225

— in delirium tremens, 176

Hypodermic needle, prejudice

against, 233

Hyperpyrcemia, theory of, 134

Hypnotic, apomorphine as, 222,

224

Hypnotics, injurious in alco-

holism, 226

— special, 225

Hysterical drunkenness, 218

Identity of patients, concealment

of, 201

Inebriates, classification of, 8-13

— indeliberate, 9— law relating to, propositions

on, 6

Inebriates Act, treatment of

patient under, 181

Inebriety, chronic, 83

Influenza, mental depression

following, 27

Injections, regulation of, 229

Insanity, alcoholic, 94— alcoholism associated with, 29

INDEX 267

Insomnia, alcoholic, 119, 169,223— apomorphine in, 222

— factor of inebriety, 41

— following worry, 16

— special hypnotics for, 225Intolerance of drugs, 126, 130Intoxicants, various, 6

Intoxication, degrees of, 152— stages of, 8

Jaureog theory of delirium tre-

mens, 168

Jealousy, effects of, 17

Kidneys, delirium tremens and,

166

— effect of alcohol upon, 100—105Korsakow's disease, 99

Lactation, prolonged, alcoholism

following, 43Laudanum drinking, alcoholism

following, 55Liberty of patients in sanatoria,

186

Liver, cirrhosis of, 106, 108

— effect of alcohol upon, 105-109

— enlargement of, alcoholic, 107

Mania a potu, 95, 129

— apomorphine in, 218

Meals, arrangement of, in sana-

toria, 203

Meat, avoidance of, 202

Medical men as patients in sana-

toria, 201

Melancholia, 95

Menopause, mental depression

and, 36

Menstruation, conditions of, caus-

ing alcoholism, 33

Menstruation, dipsomania during,

67— mechanism of, 46

Mental complications, 94— conditions associated with alco-

holism, 30— depression, factor of inebriety,

32

high blood-pressure and, 35,

39during the menopause, 36

nocturnal, 38

of convalescence, 27

post-epileptic, 36

Migraine, 50— recurrent, 133" Moderate " drinking, 165, 192

Morphine, rare use of, 235— tartrate, 234— tolerance of, 120, 125

Morphinism, 54— alternating with alcoholism, 56— tapering in, 215

Motives for drinking, 2, 5, 16

Nagging a frequent cause, 16

Name, change of, in sanatoria

patients, 201

Nausea, alcoholic, noNervous complications following

abstinence, 115, 119

Neuralgia, frontal, 53— recurrent, factor of alcoholism,

49Neurasthenia associated with alco-

holism, 45

Neuritis, peripheral, alcoholic, 96,

98

Nitrites as vaso-dilators, 46

Norwood Sanatorium, 180

" cured" cases in, 245

treatment in, 23, 237

268 INDEX

Occupations conducing to alco-

holism, 19

Operations, delirium tremens fol-

lowing, 1 17

Opium, use of, alcoholism follow-

ing, 55Overwork, effects of, 18

Pain, factor of alcoholism, 49Paraldehyde as hypnotic, 225— habit, 123

Paroxysmal diseases causing in-

ebriety, 45"Pathological" drunkenness, II,

127

Patient, treatment of, in free sana-

torium, 179, 1S8

Periodic craving, 239— drinking, 63, 76

Phobias associated with alcoholism,

3°

Physical fitness and inebriety, 57,67

Polyneuritic psychosis, 98Premonitory stages, 61, 65, 77, 79Prescriptions, 225, 227

Prognosis, factors bearing on, 257Pseudo-dipsomania, 71

— differentiation of, 79— periodicity in, 77

Psychological factors of alcoho-

lism, 9

Publicans, temptations of, 19

Pyrexia and alcoholic euphoria,

26

Pyrexial conditions; alcohol pre-

scribed in, 23

Recurrent or intermittent alcoho-

lism, 60-80

Relapses, due to minimum period

of treatment, 238— explanations of, 73, 75

Relapses, influence of, in others, 195

— statistics of, 252" Remittance man " a hopeless

type, 21

Responsibility as a cause of

drink, 17

Rest during tapering, 217

Restrictions, voluntary, in sana-

toria, 184

Retching, morning dry, 1 10

Retreats, inebriates', tone and

methods of, 181

Sacramental wine, relapses

caused by, 75Sanatoria, early treatment in, 4— free, policy in, 186

— inebriate, methods of, 180

voluntary restrictions in,

184

— statistics, 251

— treatment in, advantages of,

230

Satiety, production of, 7

Sea-voyages, risks of, to inebriates,

241

Seclusion in treatment, fallacy of

prolonged, 179

Secretiveness in inebriety, 68

Self-control, exercise of, 7, 9— weakened by indulgence, 11

Self-respect, secret drinking and,

84

Sex, prognosis and, 258Shyness causing alcoholism, 31

Sodium, bromide of, in treatment,

224

Spirits, reasons for drinking, 3Stage, alcoholism and the, 19

Statistics, sanatoria, 251

Stock Exchange, inebriates and,

INDEX 269

Stomach, catarrh of, alcoholic, 109

— lavage of, 112

Stout and lactation, 43Strychnine, injections of, 189— solution, dosage of, 231

— tolerance of, 232

— treatment by, 227

Sugars and alcoholism, 204

Suicide, prevention of, 235

Sulphonal as hypnotic, 225

Sweets and alcoholism, 204

Symptoms, 92-94

Tachycardia, paroxysmal, 49Tact in management of patients,

188

Tapering process, 104, in, Il8,

4°, 173

— cases suited for, 210

— in morphinism, 216

— principles of, successful, 212

Taste, alcoholism and, 3, 5

"Temperance" drinks, 192

Thirst, alcoholism and, 3

Tobacco, relation of, to alcoholism,

205

— smoking, tolerance of, 126

— toxicity of, 206

Tolerance, acquisition of, 168

— alcoholic, acquired, 115

— — natural, 114

delirium and epilepsy de-

pending on, 154

— degree of, estimation of, 211

— drug, establishment of, 80

— loss of acquired, 124

— of chloral, 121

— of cocaine, 123

— of morphine, 120, 125

— of tobacco-smoking, 126

Tolerance of veronal, 122

— principles of tapering and, 215

Toxaemia, alcoholic, theories of,

166-170

Treatment, 178-243

— by drugs, 217-227

— by injections, 227-237

— duration of abstinence follow-

ing. 255— question of after-treatment, 237

Trional as hypnotic, 225

Tropics, life in, and intemperance,

20

Typhoid fever, alcohol prescribed

in, 24

Uremia in delirium tremens, 166

Urine, effect of alcohol upon, 100,

104

Vaso-dilatok drugs, 46, 48

Vegetarianism in treatment, 201

Veronal as hypnotic, 225

— tolerance of, 122

Violence, outbreaks of, 1

1

Vomiting, alcoholic, 109

Water, thirst satisfied by, 3

Water cure, 245

Whisky, tapering, amounts of, 212

Will-power, absence of, 7, 10

— exercise of, 8

— relapses and, 73, 75

Wincarnis, 75

Women, prognosis and, 259

Worry, avoidance of, necessity for,

199— frequent cause of drink, 15

— insomnia following, 16

ADLARD AND SON, IMPR., LONDON AND DORKING.

Date Due

Demco 293-5

3 9002 01060 0097

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